Generalists

December 9, 2021

At the start of my 4th year of medical school in the fall of 1973, I approached a faculty surgeon for a letter to recommend me for post graduate training. The well regarded doctor was “shocked” that I was seeking a residency in the relatively new specialty of Family Practice. He noted that I had done well in surgery and could do anything I wished. I said I wanted to practice in a small town as a generalist. He said, “If you are going to turn your back on surgery, at least be an internist. Internal medicine is far more respectable than general practice”. Later, my father reiterated this same advice. Even though he lived in small towns his entire life and had always been cared for by generalists, he said I would be looked upon as more successful if I chose surgery.

A few blogs back I stated that Family Practice (FP) and General Practice (GP) were not synonymous. When the landmark Willard and Millis Commissions produced their independent reports in the mid-1960s, both essentially said, we need our GPs back. But leading GPs also recognized that poorly performing GPs could do more harm than good. So they reimagined themselves. They insisted on better training and quality oversights that exceeded those of all other legacy medical specialties. They proposed an innovative three year residency program for generalists. At least one behavioral specialist was to be on faculty of all residency programs to focus on health enhancing habits. They decided a written examination must be passed after residency as a prerequisite for board certification. They mandated periodic recertification via chart reviews and written tests to ensure that their board-certified doctors’ abilities and practices were sound and up-to-date. They renamed the specialty Family Practice.

Many of the foundational values of general practice were to be continued in the new specialty. People of all ages and genders would be welcomed. A broad range of services would be offered. Care of a person would be continuous rather than interrupted by arbitrary barriers. Patients would be welcomed into healthcare services as their needs arose rather than seeking initial care through emergency rooms or urgent portals. Initial analyses and most treatments could usually be applied by the family doctor. But appropriate referrals and services would also be recommended and coordinated by the one doctor who had a relationship with the person, their families and communities. That vision was enacted. The results have been positive. Patients who seek care from primary care doctors (mostly FPs) have experienced better health and lower healthcare costs than those who avoid generalists. Yet most Americans seem unaware of Family Practice.   

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