I am a Family Physician. Where did we come from (and why should you care)? – Part 2 of 3

McWhinney IR. Family Medicine in Perspective. New England Journal of Medicine. 1975;293(4):176–181.

This is part 2 of a 3 part series. Click here to access all the parts. In part 1 I talked about what I am. Here’s what I found out about where I came from,.

Conceived in the 20th Century as a new specialist, with a different view of “knowledge”

The problem of the primary care shortage didn’t happen recently; during World War II, medical students were given military exemptions by the U.S. Government if they pursued specialty training. Problem was, there was no residency in general practice. The GI Bill exacerbated what became an increasing fragmentation of medical practice through its incentives.

Further, medical knowledge was conceptualized as a “lump,” ever increasing, needing to be broken up into smaller bits, and managed by an increasingly narrow physician pool. 

The creators of this new specialist thought differently. They believed that knowledge of a person, their environment, and the application of medical knowledge to their situation was the most vital type of knowledge and called the lump theory a fallacy:

One tends to think of poor physicians as badly informed physicians. But everyone has encountered superbly informed physicians, who can quote all the latest references, but are woefully lacking in clinical judgment, and also excellent clinicians who in their dealings with people are incredibly naive. (McWhinney, 1975)

They didn’t want to handoff an organ system from one doctor to another, and they didn’t want to take over or diminish the role of sub-specialists either.

he will be a specialist by inclusion – in contrast to the classical clinical specialist who specializes by excluding. His aim is to broaden his concern, to widen his skill; he seeks to accept responsibility; not merely to pass it along. He utilizes specialists, rather than surrendering to them. (Wilson, 1969)

A social movement, less because of new technology, more in response to it

The kind of commitment I am speaking of implies rhat the physician will “stay with” a person whatever his problem may be, and he will do so because his commitment is to people more than to a body of knowledge or a branch of technology.

The times that ultimately spawned family medicine, the late 1960’s, influenced a generation of physicians who wanted to mirror the social change happening around them. 

There are … deeper reforms … which have motivated significant subsets of family physicians. I labeled these agrarianism, utopianism, humanism, consumerism, and feminism. (Stephens, 1979) 

Clearly we have been on the side of change in American life. We have identified ourselves with certain minorities and minority positions. We have been counter to the dominant forces in society. (Stephens, 1979)

Interestingly, while the counterculture-ness of the specialty was apparent, the point was made that the formation of family medicine may have taken the heat off of a medical profession that was becoming less appreciated by the public.

We are benevolent, well-intentioned, “humble country doctors” who only want to restore some balance to medicine. We do not want to destroy anything, or take anything away from anybody; we just want a place in the sun for ourselves and our residents and students. We are not radicals who wish to turn the world upside down. (Stephens, 1979)

In that sense, this specialty was also a preservation movement for all physicians. It appears there was even discussion (maybe heated at times?) about whether generalists should create a specialty in the first place.

I thought you already were a doctor? Where recertification came from – family medicine

An interesting bit of selflessness and protection of the future is the fact that the first family medicine specialists guaranteed that they would not hold their certification within 10 years – after that time it was required that everyone complete a 3 year residency.

In addition, family medicine was the first specialty to require periodic recertification. That’s the nod to consumerism:

The commitment to continuing education and recertification by family practice was right on target for the 1960’s resurgence of consumerism. Honest labeling of the physician’s qualifications, quality control of medical care and medical education, patient education, and patient advocacy are all consumer issues.

Prior to family medicine, the other specialties would simply grandfather their own for a lifetime. This is all changed now. This is why physicians secretly or openly prepare, study, fret, and go through this process on a regular basis. Medical school is just the beginning.

To all of the above, I say, “yep, that’s me.”

To all the social issues above, I add in my career “end to homophobia.”

What I found when I joined was a profession that lagged in human rights instead of leading in it, ironically, and it’s still very much challenged today in this area. To learn more about this part of my story, my itgetsbetter video is here.

If I didn’t have family medicine as a choice when I became a doctor, medicine would be less interesting to me, and maybe not viable at all.

For me, I think the choice was a correct one to establish family medicine as a specialty, for people who wanted advanced training as physicians in care of people, family, communities, society, AND to change the profession and society itself.

Tomorrow: what it feels like, why everyone is necessary, where we fit in the decade of the patient…

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