Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 1

This was the 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part I: Whence family medicine, and me

The history of family medicine is familiar to those of us attending this conference. Although most of us were not there “at the beginning” in the 1960s, we have heard, frequently at this conference, about the seminal reports, people, and events that led to the founding of our discipline.

The Willard Report, issued in 1966, was commissioned in 1964 by the American Medical Association’s Council on Medical Education and found that medicine needed a new kind of specialist, the family physician, educated to provide comprehensive personal health care within the nation’s complex healthcare system. It defined a family physician as one who “accepts responsibility for the patient’s total health care within the context of his or her environment, including the community.”[1]The COME also commissioned a report on graduate medical education to achieve this goal, and the Millis Report was also issued in 1966. It contained one of the earlier modern definitions of a primary physician, one who “...will serve as the primary medical resource and counselor to an individual or a family”.[2]The 1967 Folsom Report, developed by the private National Commission on Community Health Services and sponsored by the American Public Health Association and the National Health Council, called for “communities of solution”.[3]

 

Following these reports, the AMA hired two early leaders in our field, Drs. Leland Blanchard and Lynn Carmichael to “develop family practice”, and they crossed the country doing just that; Carmichael established the first FP residency at the University of Miami in 1965.[4]By 1969 there were 16 residencies. These early residencies were led by major figures in the history of the discipline, including Gayle Stephens in Wichita and Gene Farley at the University of Rochester, and grew to nearly 500 by 2016.[5]

The choice of the term “family doctor” to replace “general practitioner” was not incidental. The ABFM was founded in 1969, but the AAGP did not change its name to the AAFP until 1971, after at least 3 failed efforts. Obviously, people had always referred to their primary physician as their “family doctor” and for marketing purposes the term “family doctor” evoked positive feelings among the American people.

Like everyone here, I am sure, I can tie this to my personal story. Entering medical school in 1973, I did not come from a medical family, and think my parents had only one physician among their friends. I knew what kind of doctor I wanted to be, but not the right word for it. I didn’t even register GP; I wanted to be a “regular doctor”. You know, the kind you can go to with whatever is wrong and not have to diagnosis yourself first, and they can take care of it. As far as specialties were concerned, I guess I had an idea that pediatricians took care of children and obstetricians delivered babies. And maybe from high school friends who had money as well as acne, I knew that dermatologists took care of skin, but that was probably it. Of internal medicine, which played such a huge part in medical school, I had no concept; if anything I would have probably guessed it had something to do with gynecology, as I remember my mother having gone for annual “internal” exams.

My medical school, Loyola, had no family medicine at that time, but as I approached my scheduling for clerkships I found out that there was a physician, Werner Cryns, who ran a family practice clinic at the school. Trained as a pediatrician, Dr. Cryns had gotten private outside funds to establish this small clinic in a corner of the medical school, and I chose it for my elective. It was also my first clerkship, and from then on, I knew that was what I wanted to do. I did my residency at Cook County Hospital in Chicago, under Dr. Jorge Prieto, only the fourth full class to start in 1976. (Little side story: the hospital had always given out an “intern of the year” award, and in the first full class of FP residents, in 1973, it was won by one of them. Everyone else freaked out because “they rotate with everyone; they’ll always win it”, so there went the hospital-wide award. It became departmental.) I wanted very much to work at this public hospital with all of my socially and politically conscious friends from many of the Chicago medical schools, and was thrilled that they had a program in family medicine.

I had interviewed around the country, though, and found out about different programs, including two others that consciously saw themselves as training doctors for the urban inner city populations, Montefiore and San Francisco General. If I had gone to Montefiore, back in New York where I had lived my entire life before medical school, I likely would have had me a different life, but that cannot be known. I wanted to love SF General, as I loved San Francisco and had been unsuccessfully trying to get to California at least since applying to college, but was actually turned off by its emphasis on family dynamics and behavioral science. As someone who loved his own family but saw very much the negative impact that many families had on their children, I wanted to “keep the family out of family medicine”! Suffice it to say, I was wrong, and long since have understood the importance of the interaction of people, families, and communities, on an individual’s health.

At the 1989 Denver STFM meeting, I heard Gayle Stephens talk about “Family medicine as counterculture” (the talk was later published in Family Medicine[6]), and I admit that I was pretty surprised. I felt I had been part of the counterculture, but that doctors, even family doctors, even Dr. Stephens, were a bunch of old white guys in suits representing the establishment. I have to admit that, even though I have long since become an old white guy, and have been frequently known to wear a suit, the faces of those stern corporate-type authority figures from the 1950s and 1960s still make me anxious and a little bit hostile. (Full family disclosure, my father was a worker, not a suit.) But 1989 was a seminal STFM meeting.

I had already been attending STFM for some years, first in 1982 as a fellow at the University of Arizona, and then starting in 1985, when Dr. Prieto shared the educator award, every year since. If I make it to Toronto that will be 35 in a row. Actually, maybe it was 1988, in Baltimore, that was the seminal year, because that was the year Sen. Orrin Hatch received the Leland Blanchard award from the Foundation, orchestrated by Utah department chair and STFM matriarch F. Marian Bishop. I am sure Dr. Bishop did not anticipate, and surely did not appreciate, the antipathy of much of the younger cohort of STFM members to Sen. Hatch. From her point of the senator had been a big supporter of Title VII and family medicine. From our perspective, he was a virulent opponent of not only abortion rights, but ERA and other key issues affecting women. The only organized group within STFM opposing this was the Group on Women, which gathered signatures on a petition that was presented at the business meeting.

So, the next year, 1989, in Denver, there was a conscious effort to make a change. David Schmidt welcomed us with an upbeat and progressive speech. The Blanchard lecturer was Christine Cassel, then a professor of geriatrics at the University of Chicago and later a lot of other things, including head of the ACP Foundation and seminal in developing the “Choosing Wisely” program, speaking on medical ethics. In addition to Dr. Stephens’ talk on counterculture, Dr. Roger Rosenthal spoke about the need to care for underserved people. Several new groups were organized that year, including the Group on Minority Health, which still exists, and the Group on Universal Health Care, which had a shorter life. I felt really good about STFM and Family Medicine – and still do.

I met lots of people through family medicine – at STFM and the Program Directors’ meeting (later AFMRD), and this meeting, who were inspirational, like Frank Dornfest, the South African who was at the time program director in Santa Rosa -- the program our own Rick Flinders has written a history of -- and Gene Farley, who I met when I was a fellow at Arizona and he was chair at Colorado – an inspiration for his whole life. And some who were not old white men – Jorge Prieto, Denise Rodgers, and Carlos Moreno, and Janet Townsend, and others like David Swee and John Frey, white men who were not yet old! And the folks I worked with at Cook County – Pat Dowling, Janice Benson, and Crystal Cash, and many others. And, of course, many of those I have met or gotten to know better at this conference.

Part II: Whither family medicine, and American medicine, will be forthcoming

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[1]https://cchs.ua.edu/the-willard-report-2/

[2]https://www.nap.edu/read/9153/chapter/4#10

[3]http://www.annfammed.org/content/10/3/250.full

[4]https://www.aafpfoundation.org/foundation/chfm/collections/exhibits/carmichael.html

[5]https://www.stfm.org/FamilyMedicine/Vol49Issue4/Carek275

[6]“Family medicine as counterculture”, Family Medicine, 21(2):103-109, Mar-Apr 1989

Are resident doctors unhappy? Why?

In a New York Times “Upshot” piece on December 7, 2017, Dhruv Khullar notes that “Being a doctor is hard. It’s harder for women”. I do not doubt it, especially the second part. Dr. Khullar goes through a host of reasons for why it is harder for women, most of them related to sexism (including internalized sexism) such as having children, having the bulk of the responsibility for maintaining a household, being seen as less smart or competent by supervisors and colleagues, and on and on. The idea that “being a doctor is hard” is also one I can agree with. However, Dr. Khullar’s piece focuses mainly on residents, medical school graduates who are in specialty training. He opens it with a parody of Tolstoy’s Anna Karenina: “Happy medical residents are all alike. Every unhappy resident would take a long time to count.”

This is where I take issue, at least a little, with his perspective. Mainly this is because I do not remember being unhappy as a resident several decades ago. Tired, often, but not unhappy. I liked the work I did, as a family medicine resident at Cook County Hospital in the late 1970s, both caring for patients in the hospital on a variety of specialty services and in our hospital and community-based outpatient practices. I liked my colleagues, in family medicine and in other departments, and liked working with them. I learned a lot from them. I don’t recall most of my colleagues being unhappy either, and checked with a few with whom I am still in touch, and they also do not recall being unhappy. One, indeed, said he wasn’t even that tired, as he slept through most noon conferences!

There were not only fewer women residents and medical students, but they were (in my  experience) less likely to be married and have children. A small minority of students in my medical school class were married, but now it is common. I married (another resident) and we had our first child during residency, but when I was a program director, the majority of my residents were married by the time they started (I remember a year when five women started the program with different last names than they had interviewed with).

Yet several studies do tend to support Dr. Khullar’s assertions about residents in general being unhappy, as well as feeling overworked, and I think my experience as a family medicine program director and that of one of my colleagues (and former wife) as an internal medicine program director, support the idea that more recent residents seem unhappier, at least compared to us, then, at that hospital. There could be many reasons for this, including the possibility that memory is inaccurate, and distance dulls the pain, but I don’t think that this is the main one.

Another reason could, theoretically, be that the work was less or easier back then. Indeed, at Cook County Hospital in the late 1970s most residents had every-fourth-night call, a direct result of having a residents’ union in the hospital that negotiated working conditions. Dr. Khullar asserts that “The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties.” I think that he is wrong about this. Residents who trained in the late ‘60s and early ‘70s, before me and the union, often had every other night call (yes, work all day and all night and the next day, then go home and crash and come back to work). There is a reason that these doctors in training are called “residents” and “interns”; Cook County had a residents’ residence, where many actually lived and all had “call rooms” where we could get, maybe, a couple of hours rest. Although call was every 4^th night, there were no other “hours rules”; Cook County had 16 medical services, with 4 taking call every 4^thnight and taking every 4^th admission, and the two interns on each service thus taking every 8^th, but this could easily be 10 or more patients per intern per night. And one didn’t get to go home the next day at a certain time even though other services were on call. One specific example was CT scans; Cook County Hospital didn’t have one then, but the private hospital across the street, Rush, did. We could take our patients there, but only at night, when they were finished with their routine scans, and the patients had to be accompanied by the Cook County intern caring for them. Often at midnight, the night after they had been admitted. Residents also did most of the work; attending physicians were not in the hospital at night, and in the day had time only to round on new admissions and those who were very sick. Even having every 4^th night call was a big change from every other or 3^rdnight, but I do not think we had less work than most residents have today.

My point is not to try to disparage the tiredness or unhappiness of more recent residents by citing the “bad old days” when things were worse and we had to walk to school in the snow uphill both ways (although the weather was worse in Chicago then, thanks to global warming, and it was possible in winter to arrive and leave in the dark, and thanks to the system of tunnels under Cook County never see the sun). It is simply to note that workload is not the sole, or main, determinant of whether residents are happy or not. And here I can just speak from my limited experience. Many of us who were residents at Cook County Hospital were there for a reason. From the several Chicago medical schools and those further afield, we came because we were committed to providing the best possible care for people who were poor, underserved, and often ignored. We knew, and daily had reinforced, that our best efforts could not make up for the impact of poverty and discrimination; that despite the fact that the hospital did not charge patients, even for outpatient medications (although they had to wait hours for their prescriptions to be filled) the obstacles to their health were enormous. But we, most of us, cared, and tried to do our best. Our residency was not just a step on the path to a career as a successful physician, but an opportunity to work with and try to help people who had real need. We had a mission, not necessarily in the religious sense (although many who came as residents to Cook County were inspired and motivated by their religious convictions).

And, as a result of this shared mission we were each others’ greatest support, personally as well as medically. Medically, the 4 services with 4 residents, 8 interns, a chief resident, and medical students, shared an “admitting ward”, as so we were all together, to consult, to review x-rays, and help with procedures. But personally, we could reinforce each others’ beliefs, and provide support, succor, and even inspiration. I think that was the biggest part, for me at least.

Certainly, my experience at Cook County may not have been typical for residents of the era (indeed, that is part of why I chose it). Certainly, there were unhappy residents then, and uncommitted residents then, and women residents who were burdened with the care of the household and children. And, as certainly, there are now and have been ever since, happy and committed and inspirational residents. I guess “if you’ve seen one, you’ve seen one”. But I am pretty sure that a commitment to something greater than yourself and your self-interest helps a lot, as does training in a place where many of your colleagues feel the same way. And maybe that’s a lot of what we need as doctors, not just residents.

And as people.