G. Gayle Stephens, MD, of Birmingham, AL, is the author of many writings on the specialty, some of them collected in his The Intellectual Basis of Family Practice. In Wichita, KS, he founded one of the first family practice residencies, and he later directed a network of residencies in Alabama. In this Q&A, he reflects on the specialty's formation.
Q. What gave impetus to the shift from general practice to family practice?
A. Two parallel movements in the 1950s and 1960s affected medicine, and when they came together in a unique way, family practice was able to take advantage of it.
One of these movements was the decision to "reprofessionalize" generalpractice according to the specialty model--with certification. When a rump group within the AAGP started agitating for a specialty board of general practice, they met with opposition from the AAGP. The fight was over the scope of general practice. The GPs felt that if they organized themselves according to the specialty model, they would lose surgery, and they did. They were afraid they'd lose obstetrics, and they almost did.
The reprofessionalization movement succeeded in 1969 when the certifying board was approved.
The movement was basically from self-interest. We wanted to save our lives at the hospital level where our tails were being lopped off an inch at a time. They were closing the doors of the operating room to us. They were closing the doors of the delivery room to us. And when coronary care units came along, they were not letting us in there, either. We were being steadily chopped up.
Q. What was the other movement?
A. It had to do with reform: Medicare and Medicaid, federal aid to medical schools, medical education's decentralization, and the call for primary physicians. It dealt with the shortage of family doctors and new ideals about what a family doctor ought to be.
Three influential committees published reports in the fall of 1966. Two of them called in different ways for coordination of care, a community-based delivery system, and a "personal physician" or "primary physician" for everybody.
The other report, which came from an AMA committee headed by William Willard, MD, described what a residency would look like if it were to meet the new ideas that went beyond the general practice of the past. We had to get into behavioral and community medicine; explore the depths of the doctor-patient relationship; and create a model, office-based teaching practice.
Q. But how did the two movements come together?
A. There was a ferment going on apart from family practice. We rode the coattails of that ferment to achieve our own goal to reorganize the vocation on a specialty model.
When the reformers said the nation needed more primary care and personal physicians, we raised our hands and said, "Hey, that's us. We do that kind of work!" We were believable because we were improving and standardizing our educational requirements, not simply grinding our own axe. We were doing something that the country needed to have done--more family doctors practicing in more places, doing personal, wholistic care. We were believable because we were not identified with the problems of the system--escalating costs, fragmentation of care, distributive injustice, impersonal care.
Q. What helped the residencies succeed?
A. Three things: money from hospitals and all levels of government--local, state, and federal; the idealism of medical students who were attracted to the new residencies; and volunteer teachers from other specialties.
Q. Has there been a down side to the ideals of the '60s?
A. We got both more and less than we bargained for. Reforms have a way of twisting in your hands. You want something and you pray for something, and then you get it and it doesn't look like what you thought you wanted.
We wanted more accessible doctors. But we weren't so sure we wanted the walk-in clinics and the urgent care centers when we got them. Family physicians, nevertheless, furnished the manpower. We wanted access to emergency medical care for everybody, but we didn't necessarily want a new specialty of emergency medicine. We wanted efficient, cost-effective, comprehensive care, but we didn't foresee the shape of HMOs and managed care.
What we've dealt with in the '90s is the achievement of some of the things we advocated in the '60s in a way that shocked us. We're still grappling with this, and we don't know how it's going to turn out.
We need universal health care insurance, but that's not the direction we're going right now, although I think we will ultimately get there.
Q. What were the specialty's contributions?
A. First, we made primary care a legitimate vocation, respectable as a form of medical knowledge and skill.
Second, we brought preceptoral learning back into medical education. We made small towns like Huntsville and Tuscaloosa, AL, legitimate places for medical education. We took teaching back into the community.
It's to our everlasting credit that the GPs who fought the board were the first to get in line to take the board exam and to volunteer to teach residents all over this nation. Without those GPs to take that board exam, it would've fizzled. At one level, we opposed the board; at another level, we grasped it. We did not do this just for our own self-interest. None of the people who went into education made any more money. They made less money. And yet there were hundreds and thousands who did that.
Within a decade, we formed 370 residencies. That was never done before and hasn't been done since.
It's one thing to focus on the conflicts the board had with the Academy, but that is greatly overshadowed by the creation of these residency programs, the creation of departments in medical schools, recovering humanistic values in medical education and practice, doing community-oriented primary care, and re-emphasizing the doctor-patient relationship.
I like to use a ballistic metaphor since I was in Huntsville. We altered the trajectory of medicine. We bumped it off course. It's now going in a little different direction than it would have gone in if we hadn't been there.