The anticipation before starting medical school is immense: fears about gross anatomy, wondering about classmates, anxiety about moving to a new place, and excitement about starting a life-long career of service to humanity. Most first-year medical students have some ideas and dreams about the future. I was no exception. With strong roots in rural Montana, I envisioned doing clinical practice in a small town out West, and my dreams included international travel and volunteer service as well. Although I had little knowledge about medical specialties, I thought family medicine would suit me the best. Naively, I assumed that the core curriculum and opportunities at all medical schools included exposure to and training in the specialty of family practice.
In reality, there are 10 medical schools in the United States without academic departments of family medicine.1 This number is down from the original 22 schools that were designated as “target” schools by the American Academy of Family Physicians (AAFP) in 1988. These target schools are removed from the AAFP's list once a family medicine department is established (including the hiring of a department chair and faculty, as well as establishing a clear presence of family medicine in the curriculum).1
Within two weeks of my medical school matriculation in 1993, I discovered that I had unknowingly chosen an “orphan” school. My medical school did not have a department of family practice. In fact, the words family medicine were rarely spoken. On one occasion early in my first year, I was publicly reprimanded for asking a question about the absence of family medicine. I was told, “That question, young lady, will get you in a lot of trouble around here. It's best to just forget about it.”
I refused to forget about family medicine. It took two years before I had the courage to admit that I was seriously thinking about family medicine. I could usually avoid harsh comments by responding to curious questions with the politically conservative response, “I'm interested in primary care.”
Most people would follow up by asking, “Have you decided whether you will do pediatrics or internal medicine?” I usually just shrugged and said, “Not yet.”
Once third-year clinical rotations started, we were bombarded with questions about our specialty interests. Most of my colleagues expressed priority interest in whatever specialty they happened to be visiting for the month. I continued to communicate my interest in primary care. When probed further about pediatrics or internal medicine, I began to actively complete the primary care triad by mentioning family practice as an option as well.
“You're kidding…” was the response I usually got fired back at me. After a few seconds of silence and no laughter, someone might question “…Right?”
Then, they would usually go into a short discussion about the novelty or absurdity of choosing family medicine as a career. I encountered a year of brief narratives that followed, “You're kidding…(silence)…Right?”:
“I wanted to do family practice, too. Then, I got smart and found out about real medicine.”
“Oh, cool…family medicine is what real doctors do!”
When I asked for permission to attend the AAFP Student and Resident Congress in August: “No, you cannot have time off from this rotation to attend a family reunion picnic.”
“Family medicine? Wow! That's what the smartest and most capable medical students choose to do.” “Don't waste your medical education by doing family medicine.”
“That's great! Family medicine is the kind of medicine that most of us envisioned doing when we first applied to medical school…the real ‘country doctor’ image!”
“What is family medicine?”
And, the comments continued. The responses varied. Some people were encouraging; others were discouraging. Most people were intrigued and wanted to give their opinion to the rare student who came along at our orphan school with an interest in family medicine. Although I had heard criticism and negative comments, most were rooted in ignorance rather than disdain. When I look back over three years of medical school, I am amazed that a student can complete several years of training at an orphan school and never meet a family physician. In fact, some of the only references to family practice made throughout my first three years were about family physicians in the community hospitals who made mistakes, or who were too lazy to attend morning rounds on their patients in the urban tertiary care hospital (three hours away). Unless a student sought a specific opportunity to experience family medicine, mentors in family practice were shockingly absent. By my third year, I realized that I needed to find “parents” and mentors to support my interests in family medicine. I also hoped to equip myself with knowledgeable responses to the constant barrage of questions. So, I embarked on a search of my own to find out more about the specialty.
While researching the origins of the specialty of family medicine, I was surprised to discover that the American Board of Family Practice (ABFP) was only established in 1969. In the 1930s, more than 80 percent of practicing physicians were general practitioners.2(p351) Yet, the American Medical Association (AMA) refused to grant the request of leading general practitioners (GPs) for a general practice specialty board in 1940.3(p17) Soon thereafter, the GPs formed the American Academy of General Practice (AAGP) in 1947.2(p352) In 1950, the AMA received a report from its Committee on General Practice saying that too many specialists and too few generalists were being trained. However, there was still widespread opposition to the creation of a specialty in family practice. In fact, many of the tensions existed within the AAGP. For example, in 1962, the AAGP Congress of Delegates voted against an idea to create a specialty board while the AAGP's journal, GP, published an article written by the AAGP Executive Board and the AMA Section on General Practice entitled “An American Board of General Practice for Family Physicians.”2(p352) Amidst the controversy, the AMA commissioned committees to conduct two influential studies. In 1966, these committees issued reports that outlined a foundation for family medicine and designed a structure for family practice training.2(p355) And, they decided on the term “family physician.” The committees considered several other terms including: general practitioner, personal physician, first contact physician, comprehensive care physician and primary physician.2(p355)
The Liaison Committee for Specialty Boards was reluctant to recognize a proposal from the ABFP advisory group to make family practice a formal medical specialty, and the application for an official family practice board was denied in 1968.3(p18) However, in February 1969, family practice was approved as the 20th American specialty.2(p352) An official ABFP was established. Nicholas Pisacano, M.D., became the first ABFP executive director and led the board through early identity-defining decisions about examination, certification and recertification. In 1969, 15 family practice residencies were approved, and the first board examination was administered in 1970. One decade later, there were 382 family practice residencies and 6,735 residents were in training.2(p355)
So, what does this historical vignette mean to a medical student today? For me, it helps explain the relatively recent establishment of family practice as a distinct academic medical discipline with an approved board, certification examinations, university departments and residency programs. I had naively assumed that family medicine as a discipline had been practiced for centuries; therefore, family practice must have always existed everywhere. Knowing the background of the specialty, I can understand family practice in the wider context of medical professionalization and the emergence of medical specialties.
With a basic understanding of the history of family practice, I am better aware of the politics involved in creating departments of family medicine. While some universities have well-established departments, others have a lot of catching up to do. For students at orphan medical schools or sites with few resources in family medicine, it is essential to find mentors and role models who can present a balanced picture of this amazing new specialty of family practice. These people can act as “parents” to support and advise “orphan” children. Although my school does not have a formal family practice department, I received support from primary care groups and mentorship programs. I also found mentors in Helena, Montana, where I spent six wonderful weeks doing an elective clerkship with family physicians in my home community.
Neighboring medical schools and family practice residency programs were amazingly helpful with elective offerings and residency information. The AAFP was a phenomenal resource for me and supported my attendance at regional and national conferences where I was able to establish communication with students, residents and faculty across the country. Connections to AAFP programs such as the Family Medicine Interest Groups also provided opportunities for students at my school to network with other groups and family practice programs.
I am grateful for the mentors who offered me support. These people and organizations helped strengthen my interest in family medicine. Being at an orphan school also heightened my awareness of the important role that every one of us can play in the future of our specialty. Even as a medical student, my contributions mattered. At a school without a family medicine department, I was often considered the local expert called on by younger students with questions about careers in family medicine. Because I had wonderful mentors, I knew the importance of taking a few extra minutes each day to offer encouragement and support to students interested in family medicine. Together, we must all contribute our time, enthusiasm, knowledge and spirit as “parents” of family medicine.
editor's note: Dr. DeVoe's experience is not limited to the so-called “target” medical schools. Without singling out any one medical school in particular, we felt that her story was representative of the negative attitudes that some students interested in family practice still face, and the important role that good mentors and role models can play.