In that it appears there is no longer conversation on L-stone, I submit this
archived article as closure to a truly academic conversation. Hershey Bell
help move us to this point. I for one will miss his thought provoking
contributions. I hope this article will give insight into a part of the
thought process that led to the development of family medicine. Try to
imagine yourself at this period of time and what your thoughts might have
been if you were in a position to begin a new "specialty". In many ways the
ideas below hold true today. I wonder if our brothers and sisters in the
social and behavioral sciences feel we have reached any of these goals?
I hope the dialog at Keystone as well as dialogs like L-stone will continue
and carry us successfully into the future.
Lawrence
Published in JAMA, Jan. 4, 1965. Volume 191, No. 1
By Lynn Carmichael, M.D.
Teaching Family Medicine
Medical education is concerned with the future, that is, the production of
physicians for the future. The role of the medical practitioner will depend
upon the medical needs of the community he/she is to serve. An implicit
obligation of medical educators is to define these needs, an act
accordingly.
The Needs of the Public.--This is a period of rapid social change.
Traditional virtues and standards of conduct are being discarded. Society
is becoming more diversified and complex, more interrelated and
interdependent. Our population is expanding. We live longer, have higher
standard of living, and enjoy more leisure. The work we do is more
productive and yet easier. All of this will effect medical practice of the
future, even more significant are the changes occurring in the American
family marriage was never more popular, nor held in higher esteem by both
men and women. An expression of this is the eagerness of young people to
marry and the trend is for earlier marriage and fewer children for family.
Be it caused or effect, the larger family is frequently at a social or
economic disadvantage. There has been some increase in the proportion of
broken homes, but most American marriages seem to be stable. Presently 87%
of all children live in the same household as one or both parents. Along
with a tendency towards the smaller family is a telescoping of the child
bearing years. More than 50 percent of mothers have completed childbearing
by 26 years of age. The net effect of this is freedom from pale
irresponsible are many middle-aged couples.1
Progress has brought about many changes in the status of the women. She
marries earlier, promptly bears her children, and is free to enter the
workforce. She has attained social and legal equality, and no role seems to
be denied her. Her aspirations can realistically include the highest
offices in the nation. Advances in the techniques of contraception allow
woman for the first time to control fully her reproductive powers. The
consequences of this factor society have yet to be realized.
The attitude of society towards disease and health is shifting; there
is less resignation to disease and more anticipation of health. The nation
has experienced a reduction in infant and maternal mortality, and we can
anticipate a further drop. Epidemics of communicable diseases are
disappearing and death due to acute disease is becoming rare. On the
increase is disability from the genetically determined an emotional illness.
In the future death will be due more and more to accidents, neoplasm, and
the degenerative diseases.
In the years to, health education and disease prevention will be a
paramount importance. Early recognition of disease and modification of its
course will be stressed. A given pathological disturbance will no longer be
attributed to a simple or single cause.
(There are, instead, complex situations and environments in which the
probability of certain events is increased. In most biological phenomenon
toward cause is a semantic trap.2)
Psychological, sociological, and economic considerations will be as
important as pathophysiology in arriving in a diagnosis. Most illnesses
medicine will encounter will not be cure bowl in the traditional sense.
Treatment will be directed towards symptomatic relief and disability
reduction; control, not cure will be the objective. The physician will do
less to and more for his/her patients.
The health care team will extend its effectiveness and efficiency in
all spheres. The duties of the visiting nurse will be health promotion,
home care, and personal performance of screening examinations. The social
worker will assistant history evaluation, environmental manipulation, and
the coordination of community resources. The trend will be away from
curative services and present-day medical specialists will become clinical
technicians and research scientists. Institutions concerned with health
rather than disease will be developed. Hospitalization will represent not
the epitome, but the failure of medical care.3
The health needs of the American family are changing, and so must
physician who services these needs. If the above projections hold farm the
physician of the future will greatly differ from that of the present.
His/Her concerned will extend throughout the medical life of a person. The
emphasis will be on health maintenance and disease prevention, and, as such,
the family physician will be a cross between the private practitioner and
the public health doctor. His/Her primary interest will not be the
individual, but the basic sociological unit of our society, the family.
His/Her discipline will be family medicine. Family medicine differs from
the other specialties both in the extent and level of its interest.
Family medicine is not general practice. The latter is disease
centered and based on at the site care. Family medicine is health oriented,
and offers comprehensive attention to the family. It features continuity of
health management, not just continuing care of the specific illness. Family
medicine has a definite body of knowledge; since a line can be drawn about
it, we can say what it is and what is not. Instruction in family medicine
is possible and preparation for its practice can be offered. Family
medicine will require specially trained physicians, not physicians half
trained in the number of specialties.4
On admission to medical school certain characteristics are present in
the student that permit prediction of the specialty he/she will alternately
select.5 The admissions committee of a medical school plays a significant
part in determining the specialty interest of its graduates. Since most
admission committees are composed of basic medical scientists and clinical
specialists, it is understandable that they tend to select candidates in
their own image. Here than is the first responsibility the medical school
has in meeting the needs of the public. The school must admit students who
possess the qualities in attitudes found in good family-medicine
practitioners. Just what these qualities are and how to determine if a
given student has them is no simple task. This area is presently under
intensive investigation, and promising results have been obtained.6
Preparation for family medicine practice begins in medical school. The
type of patient and a variety of conditions the physician of the future will
encounter require different knowledge and skills than presently found in
traditional curative medicine. As stated earlier the emphasis will be on
disease prevention and, failing that, early presymptomatic recognition. To
prepare the student for this role his/her pre-clinical education must
include instruction in the behavioral sciences as well as the biological.
A good physician needs a certain fund of knowledge and the ability to
apply this. These skills can be divided into four general categories:
cognitive, perceptive, manipulative, and affective. The cognitive skill is
the ability to apply the factual information he/she has gathered in this
training. Perceptive skills deal with the ability to use the senses
effectively to detect slight but significant deviation from normal, whether
organic or functional. The mastery of the motor abilities so necessary in
curative procedures constitute the manipulative skills. The final category
is perhaps the most crucial. The affective refers to the physicians skill
in using the doctor-patient relationship. Since family medicine is
dedicated to health maintenance, training in this field must concentrate
more on developing the perceptive and affective skills and less on the
cognitive and manipulative.
George Orwell introduced the phrase "double-think." An example of this
is the Ministry of Peace dedicated to and training its personnel for war.
Let us avoid double think; war is not peace, health is not disease.
Hospitals are concerned with disease, family medicine with health. Is it
logical to center the training for family medicine in the hospital? As this
physician will practice in the community, his/her training should be based
on the community, not the hospital. The teaching hospital offers
residencies to the hospital-based disease-oriented specialist. Another
institution, the family health center, could provide training for
community-based, health-oriented family medicine practitioner.
continued....
The Medical School Program.--the first step in developing a program of
undergraduate education is to define the objectives of the program. That is
to state explicitly what the student is expected to large, and what changing
behavior should occur in the student. Since most agree the medical school
should produce the undifferentiated physician, acquisition of skills in a
particular field should await graduation. What then are the goals of family
medicine program at the undergraduate level? Presently they would seem to
be three fold: (1) To provide the medical student inclined towards family
medicine and intellectual home, and faculty member with whom he/he can
identify. (2) To introduce a concept of family medicine into the academic
environment. (3) To demonstrate to the students, faculty, and a medical
profession that family medicine is a legitimate discipline, and that the
care given is in all aspects comparable to that rendered by other
specialties.
An elected program offered to third-and fourth-year students would
satisfy these names. Each student would be assigned of family, and he/she
would serve as their family physician under close supervision. The families
selected for student assignment would have to be family-doctor oriented, and
should rep reached a broad spectrum of social class. The director of such a
program must be a family physician with a full-time faculty appointment. A
demonstration family practice within the family health center and located
year the medical school and the teaching hospital would furnish the patients
facilities and a realistic setting for the program.
The Internship.--The intern year is a transitional period. The newly
graduated physician gives up the passive role of the student, and begins to
assume responsibility for patient care. This is more important than the
acquisition of skills, and as long as a certain level of quality is
maintained, the exact nature of the intern experience is not critical.
Presently students interested in the primary care disciplines elect
rotating first-rate internships in internal medicine or pediatrics.
Preparation for family medicine at the internal level is hospital centered,
and differs from the above only in orientation. Therefore, while in
internship in family medicine is desirable, a physician who was completed a
rotating, mixed, or straight internship in medicine or pediatrics would be
eligible for admission to the residency program.
The Postgraduate Training Program.--The resident in family medicine
will be based at the family health center, and will participate in all is
educational activities. He/She will receive instruction at the medical
school and his/her duties and responsibilities at the affiliated hospital
will be similar to medical or pediatric residents at the same level of
training. The inter-relationship of the three institutions involved in the
family medicine residency is illustrated in the venn diagram (Figure)
The program would be of three years duration, and should satisfy, in
part, the present board requirements of pediatrics or internal medicine.
The important features of the program are as follows:
(1) Each resident would be assigned a number of families to follow
throughout his/her training program. He/She would serve as their family
physician. Care would be given at the family health center, home, and
hospital. He/She would gain experience in using the various community
health resources, and working with the health team. His/Her activities
would be closely supervised by the professional staff of the family health
center.
(2) At the hospital he/she would be assigned to the inpatient services
of medicine pediatrics, and attend the specialty clinics. He/She would
rotate to the outpatient departments of surgery, obstetrics, and psychiatry.
In the early part of the program the resident will spend considerable time
on the casualty services and in the emergency room.
(3) The family physician needs an appreciation of the medical aspects
of sociology, social psychology, and social anthropology as well as an
understanding of the interaction of society in disease. The university is
able to offer courses and seminars in the social sciences, and the resident
will be expected to participate. The disciplines of prevented physician
should also be available for the instruction of the resident.
(4) An assignment with a county health department or to another
community project would broaden the residents' understanding of public
health practices and social problems.
(5) Each resident would be required to participate in research, and
make an investigation into some aspect of medical care.
At the completion of the program a degree might be awarded by the
University, perhaps a Master of Science in Family Medicine. This would
certify as to his/her competency in this field.
Conclusions
The future health needs of the public are the prime consideration of
medical education. A system of care based on family medicine seems to be a
logical and affective method of meeting many of these needs. Medical
schools should offer courses in family medicine, and training programs
should be devised. Finally, research projects should be designed to
investigate the effectiveness at acceptability of this form of medical care.
This investigation was supported by a fellowship from the United States
Department of Health, Education, and Welfare. Welfare Administration,
Children's Bureau.
References
1. Watson, W. : The American Family; President and Future Implications for
Family Medical Practice, read before the Williamstown Conference on the
General Practitioner and the Physical and Mental Health of the Family, Jan.
21, 1964.
2.Shemkin, M.B.: "Hormones and Neoplasia," in Cancer, Roven, R. W., e.g.
One didn't: Butter Wirth & Co., Ltd., 1957, p. 161
3. Greenhill, S.: Personal Communication to the author, April 2, 1964.
4, Haggerty, R.J. General Practice: Extinction or Rebirth, Harvard Med
Alumni Bul 38:23-28 (Fall) 1964
5 Schumacher, C.F., Personal Characteristics of Students Choosing
Different Types of Medical Careers, J Med Educ 39: 278-288 (March) 1964
6 Bruhn, J.G., and Parsons, O.A.: Medical Students Attitudes Toward Four
Medical Specialties. J Med Educ 39:40-49 (Jan) 1964