In outlining the similarities between political and scientific revolutions, Thomas Kuhn describes the former in a way I’d like to take out of context, because it seems peculiarly applicable to family medicine today: “Political revolutions are inaugurated by a growing sense, often restricted to a segment of the political community, that existing institutions have ceased adequately to meet the problems posed by an environment that they have in part created.”1 Kuhn goes on to say, essentially, that those who agree that the old order is passing away may well disagree on what should replace it, and they will certainly disagree with those who continue to support and defend the current institutions. “At that point the society is divided into competing camps or parties, one seeking to defend the old institutional constellation, the others seeking to institute some new one. And, once that polarization has occurred, political recourse fails.” That is, the competing camps no longer have enough of a common framework even to agree on how to disagree.
I think we’ve almost reached that point in health care. Nothing quite seems to work the way it should, and efforts to shape the future range from the conservative (e.g., the pay-for-performance programs discussed in this issue) to the radical (e.g., the efforts of the leaders of family medicine to rebuild the specialty). Discussion of the future has become strident, with angry outbursts threatening to supplant reasoned discourse as parties in all camps feel threatened. We seem headed for chaos.
But while it is an ugly time, it is fruitful as well. When what we have doesn’t work and what will work isn’t clear, experimentation flourishes. We get, for instance, ultra-low-overhead “micropractices.” We get cash-only practices, Web-friendly practices and house-call-only practices. We get the TransforMED National Demonstration Project. We may not recognize it as it happens, but somewhere the future is coming to be. Whether it’s the Future of Family Medicine or some other, lower-case future, we are privileged to be present for the delivery.