Remembering 40 Years, Plus Or Minus
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J Am Board Fam Med: first published as 10.3122/jabfm.2010.S1.090293 on 5 March 2010. Downloaded from Remembering 40 Years, Plus or Minus G. Gayle Stephens, MD In July 1967, I went to work at Wesley Medical vision for general practice and doctoring families Center in Wichita, Kansas, with 2 tasks. One was to and wanted to participate in that. transform the existing Residency in General Prac- tice into a new Willard Report-style Residency in How It Began to Happen Family Practice. The other was to organize a group Dr. Jack Tiller, late father of recently assassinated of medical staff physicians to provide round-the- George, was the volunteer director of Wesley’s clock professional services in the Wesley Emer- General Practice residency, and he graciously gency Department. I am pleased to report that both agreed to the transformation and my appointment projects are functional today. as Director. I mention this here because the new Presumptuous and cocky at age 39 and having Family Practice residencies were not created from lied to my wife about how much more orderly our nothing. lives would become, I moved my practice to a The Residency Review Committee for General 2-story bungalow on the Wesley campus. Seven Practice reported in 1965 that there were 198 ap- hundred of my patients indicated their willingness proved graduate training programs. These were of to join me in this adventure and 1000 actually came 4 types: 2-year general practice residencies after to the new office during its first year of operation. internship in 165 hospitals offering 783 positions What I remember most clearly about this move and 47% filled; 22 pilot programs of 2 years’ dura- was my sense of excitement and optimism about tion, 14 of which offered obstetrics and 8 did not; 1 changes in medical care; it seemed the nation was and 15, 2-year internships. prepared to reform its chronic problems—the doc- These programs were in 39 States, the District tor shortage, escalating costs, unjust distribution of of Columbia, and Puerto Rico. Most were in Ohio medical services to rural and inner-city popula- (27); California, Michigan, and Pennsylvania (14 tions, and fragmentation of care among generalists each); Illinois (12), and Virginia (10). Interestingly, and specialists. Our Sedgwick County Medical So- 9 were in medical school settings and 6 were in ciety had led a successful campaign in 1962 to 1963 military or United States Public Health Service settings.2 Moreover, 9 were included among 17 http://www.jabfm.org/ to immunize free of charge all willing citizens with programs in development that accompanied the the oral polio vaccine. The Medicare and Medicaid application for creating the American Board of amendments had been passed by Congress in 1965, Family Practice. and the “Summer of Love” was happening in San It is clear that what was going on in Wichita Francisco. during 1967 was going on elsewhere and that im- Darker things were happening too. The Civil portant changes were occurring in medical educa- on 2 October 2021 by guest. Protected copyright. Rights Movement experienced “Bloody Sunday” in tion, not only for general practice but for graduate Selma; the Gulf of Tonkin Resolution passed in medical education among all specialties. I was re- 1964; and 1968, an Annus Horribilis, was around the sponding to having read “Meeting the Challenge of corner. Nevertheless, a light had gone on in my Family Practice,” the Willard Report, published in head in the fall of 1966 when I first read the famous 19663 (fortuitously, as I understand it) within 6 reports (Willard, Millis, and Folsom) and saw a new months of 2 other auspicious reports named for their chairmen: Folsom and Millis.4,5 It was not clear, however, who was meant to From the University of Alabama School of Medicine, respond to these reports or how. Dr. Willard him- Birmingham. Funding: none. self seemed rather tentative on this point in an Conflict of interest: none declared. article he wrote in the Journal of the American Med- Corresponding author: G. Gayle Stephens, MD, 4300 6 Overlook Road, Birmingham, AL 35222 (E-mail: ical Association in 1967. He cited a letter from a [email protected]). medical school faculty member who raised the doi: 10.3122/jabfm.2010.S1.090293 Remembering 40 Years S5 J Am Board Fam Med: first published as 10.3122/jabfm.2010.S1.090293 on 5 March 2010. Downloaded from question of sponsorship and suggested “some joint vised counseling, with special awareness of the fam- venture would be desirable by a number of medical ily as a unit of care; awareness and utilization of schools and hospitals.”6 community resources; and appropriation of social It turned out that Executive Mac Cahal and the and behavioral sciences. Although not mentioned American Academy of General Practice (AAGP) in the Willard model, the clinical record was also was ahead of Willard. In his Annual Report of the being remodeled to the “problem-oriented” format Executive Director, published in March 1967, Ca- as taught by Larry Weed8 and others. hal wrote that he had read all the “reports” and that In our 2-story Wesley bungalow and after 1970 the AAGP was ready with a core curriculum for the in remodeled quarters at the former Sedgwick new residencies and even ready for a change of County Hospital, located in a low-income neigh- name of the AAGP to reflect its new educational borhood, our staff included a medical social worker mission. Coyly and modestly he proffered that the and we provided nutrition education in a demon- new name should properly be “American Academy stration kitchen, psychiatric supervision; we also of Medicine.”7 had a strong liaison with a clinical pastoral educa- Mr. Cahal was also ahead of his organization and tor. Residents and faculty served as high school its officers and members in actually implementing team physicians, and they attended at a methadone the changes called for in the Willard Report. Al- clinic and a Methodist Urban Ministry house for though the Folsom Report called for a personal street people, troubled teens, and the temporarily physician for families and the Millis Report called homeless. for a new primary physician, neither specified that Similar models of expanded family doctoring members of AAGP were meant to serve in these were springing up around the country under vari- roles. In fact, Millis fancied a more grandiose ous sponsorships and financial arrangements. In model of the primary physician as one delivering retrospect, although these new residencies gener- comprehensive health care, acting as the “quarter- ally followed the Willard Report, a good deal of back” of the team, the “company president,” or the local creativity and financial support actually were “senior partner in a law firm. ” It would be arro- being devoted to the creation of the bureaucracies gant, he said, to speak of these generalist roles of a new medical specialty. The American Board of derogatorily. Family Practice was approved in 1969, the first new Nevertheless, generalist physicians of various ac- primary board since 1949. Basically, we were using ademic backgrounds were raising their hands in the accreditation of the general practice residencies response to the call. I discovered Lynn Carmichael (already alluded to) until the Residency Review in Miami, Florida, who was directing a straight Committee for Family Practice first established http://www.jabfm.org/ internship in Family Practice with 12 positions new essentials for residency training. filled in Jackson Memorial Hospital. Roger Lienke, a pediatrician, moved from Minnesota to Okla- homa City, where he was developing a residency at Unprecedented Success Mercy Hospital under the sponsorship of the Uni- The availability of Board Certification was neces- versity of Oklahoma School of Medicine. Eugene sary, but not sufficient to explain what actually on 2 October 2021 by guest. Protected copyright. Farley was doing the same at Highland Hospital in happened. It unleashed an unprecedented torrent Rochester, New York, as was Ian McWhinney at of residency program development nationwide: 375 the University of Western Ontario in London, On- programs by 1975. By comparison, pediatrics de- tario, Canada. veloped 150 programs in the decade of 1935 to The new models of graduate education for fam- 1945. ily physicians called for a dedicated and identifiable The catalyst for Family Practice, in my view, was “model family practice center,” where residents, the reform ethos of the 1960s that tapped into deep faculty, and other members of the team cared for springs of American idealism and values—agrarian- defined groups of patients, providing comprehen- ism, humanism, civil rights, feminism, and distrib- sive and continuing services on a regular basis, utive justice. These ideals and values shaped the including an off-hours on-call schedule. new discipline in ways not imagined by organized In addition to traditional clinical services for sick medicine. The new programs attracted faculty and patients, we emphasized preventive services, super- medical students because they had a new vision of S6 JABFM March–April 2010 Vol. 23 Supplement http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2010.S1.090293 on 5 March 2010. Downloaded from medical education and the roles of physicians and Table 1. Living Graduates of Family Medicine (83,616 ؍ other health professionals. Nowhere was this Residencies from 1969 to 2007 (n change more visible than in the formation of the American Board of Family Medicine Diplomates 83.5 Society of Teachers of Family Medicine, which Women 36.6 joined physicians with educators, psychologists, so- International medical graduates 16.7 cial workers, and administrators to learn how to Doctors of Osteopathy 10.4 implement the new strategies.