_ GEYMAN 593 Vol 298 No I I FAMILY PRACTTCE IN EVOLUTION
SPECIAL AßTICLE
FAMTLY PBACTICE IN EVOLUTION Progress, Problem¡ and Projections
JoxH P. Cevuan, M.D. Abstract Family practice has developad in direct and graduate levels throughout the country in both response te the public need for primary care with the univelsity and community settings. Refinement of elernents of comprehensiveness, continuity and ac- teaching programs and initiation of a strong ongoing cessibility. This specialty represents a re'Bmphasis of research effort are now requireci' The continued suc- the generalist role in medicine, with partic¡'lar con- cessful evolution of family practice as a foundation of cern for the family as the unit of care. Since the primary care in the United States is essential to extend American Board of Family Practice was formed nine ifre frignest possible quality of care to lhe entire pop- years ago, the first phase of development has been ulation at a cost that can be aflorded in a society with êompleted. Teaching programs in family medicine limited resources for health care. (N Engl J Med have been etfectively established at undergraduate 298:593S0'l, 1978)
an as' VER ten years have now passed since the pub- families, whereas pediatrics represented such lication of the three major national reports that sertion for the care of children (specialty board rePresented together served as a foundation for the genesis of fami- formed in 1933) and internal medicine (specialty ly-practice in the United States: the Millis, Willard such an assertion for the care of adults a.,d Foltott, reports.r'3 It has been nine years since the board formed in 1936). That the idea of a broad- forrnation of the American Board of Family Practice. breadth specialty dealing with the health-care needs The period of initial development of this new specialty of famiiies and individual Patients' regardless of age or ef- was occupied primarity with the tasks invoived in es- sex, is not new is evidenced by the fact that formal tablishinf teaõhing programs in family medicine for forts were previously made within the American medical itudents and residents' with less attention to Medical Association in 1919, and later in 1941, to es- other necessary elements of the specialty's develop- tablish a board ol general practice. ment. This phase has now been largely completed, Family practice has also been seen as representing preven- and a second phase of further maturation is starting. an increased concern for health maintenance' It is important at this stage of transition in the tion of disease, long-term care of chronic illness, development of family practice to ¡eassess its progress, rel¡abilitation and counseling for common health current problems and future directions. The progress problems. It must be admitted that its predecessor, in of the field to date will be described in relation to the general practice, as well as many other disciplines more critical issues initially encountered by the äedicinà, has focused more strongly on episodic care charged specialty as it emerged in the late 1960's. Four impor- of acute problems. Family practice has been the tãnt issues currently facing the specialty will next be with the need to integrate behavioral science with discussed, which then ;vill permit consideration of care of organic medical problems as well as to co' projected future directions in the field. ordinate the patient's overall health care in the con- text of his or her family and available resources within B¡crcnouxn rxP lxrr¡.rr, ãat{tgs the community, including consultants in the more The recognition of family practice in 1969 as the limited specialties. 20th specialty in American medicine is of interest in a Stephens, who views this development as a reform numbèr of respects- It represents a re-emphasis of the moueàent in response to major cultural, social and generalist role in rnedicine, with particular concern political trends, has presented an interesting perspec- ior the family as the unit of care' comprehensiveness tive of the genesis of family practice: and continuity of personal care and rcady access to The medical establishment itself is created to a considerable care. Thus, at a time when the number of primary- degree by forces that originate in the larger social order - forces care physicians had been steadily decreasing, despite of political, economic and cultural significance for society as a practice education bcars a population with increased expectations for whàle. It is my belief that family a growing relation to these external forces, major rpecial, perhaps even ã unique, health care, family practice was seen as a and thaiits curcnt significance and its futurc devclopment lie in { response to the mounting dehcits in primary care. ou¡ understanding of these forces and rclationships Thls development therefore repr€sents an as$ertion of generalist role the health care of the need for a in Since family Practice had no formal place in medical education in the United States before 1969, a number of major issues were immediately raised as From the Dspartmcnl of Family Mcdicinc (RF 30)' School of Mdicinc' the new specialty took root. Perhaps the most impor- whcrc rcqust¡ should Univcnity of Washinglon, Scattla, WA 9tt95, rcp¡i¡t What is the bc addrcsscd lo Dr. Gcymaa. tant issuei can be summarized as follows: THE NE,W ENCLÀND JOURNAL OF MEDICINE March 16, 1978 academic discipline of famiiy practice? How can Organlzetlon ol Toachlng Progrtmr teaching programs be organized practice? in family The development of teaching programs in famil,v What should bc the content of curriculum in family- practice, at both undergraduate and graduate levels, practice programs? Can faculty be recruited teach to has been the principal thrust in the ñeld to date in the in dcveloping programs? Can interest among medical United States. The growth in numbers bf programs students in this emerging specialty be developed and has been impressive in a short span of years. Table I sustained? And will graduates family-practice of and Figures 1 and 2 reflect this growth at the un- residency programs locate areas need? in of dergraduate and graduate levels, respectively. At the undergraduate level, emphasis has been placed on progressive exposure to family medicine Procnrss ro DATE during all four years of medical school. Family- thc Academlc Dlrclpllnr practice faculty membe¡s are often involved in the teaching of "Introduction to Clinical Medicine" In the early years of family-pracrice development, courses (history taking and physical diagnosis), considerable attention was paid conceptual to the preceptorships, clerkships, preventive and community definition of its academic discipline. There was some medicine and related areas. Barnettt has presented an controvercy on this issue, and the attempts by some to excellent overview of the philosophy and content ol focus primarily on its unique content as different from undergraduate curriculum in family medicine in one all other disciplines blurred clinical the debate for a medical schooi, and case studies of three additional time. It is diflicult even impossible to defìne with undergraduate programs in family medicine have precision - - the distinguishable body of knowledge in recently been published.e any broad clinical specialty, such as family practice, internal medicine and pediatrics. Family practice, as the broadest held in medicine, incorporates in a par- Table 1. Organizational Units lor Family Prsctice in Medical ticular way portions of all other clinical disciplines Schools.' and related fields. UNn Xunsr In an excellent paper that directiy addressed this question, Mcrrllhinney proposed four essential criteria Dcpañmcnts E4 Divisions 13 for the dehnition of any academic discipline: a dis- Othcr programs 4 tinguishable body of knowledge; a unique lìeld of ac- Dcpartmcnts underdcvclopmcnt 9 Sehools wittout activity 2l tion; an active area of researrh; and a training that is Total ¡:l intellectually rigorous.s Use of all these criteria enlarged the definition rDst¡, æmpilcd by Divûion of Êiwtioa, AffiirÐ Aqdøry of Fuily Pby¡icians, of the academic discipline of Kro City, MO, ¡s?lwnt ¡li mcdiel æhæl¡ i¡ thc Unitcd State, iacluding bmch famìly practice. It became clear that content alone mprc & mcdiel shæl¡ nor yú fùIIy aercdit¡d but ín u sdvsnæd stågc of devçIotr could not adequately define this discipline, and that a functional definition was required. The term "family medicine" has therefore evolved as the academic dis- At the graduate level, residency development has cipline of family practice. It can be defined as the been based upon the Essntials for Graduak Training in body of knowledge and skills applied by the family Famiþ hactice, a document jointly completed in 19ó9 physician as he or she provides primary, continuing by the American Academy of Family Physicians, and comprehensive health care to patients and their American Board of Family hactice and Section on families regardless of their age, sex or presenting com- General/Family Practice of the American Medical plaint.ó Association. These Essmtiak call for three-year Other specialties havc defined themselves on the residency programs combining ambulatory-care basis of anatomic areas, age or sex. Family medicine training in a continuity-of-care setting (family- cuts across territorial boundaries of all the traditional practice center) with hospital-based training in the specialties, and varies in its application by each family traditional specialties and additional training in a physician based upon his or her own training, in- range of subspecialty areas. Many of these residency terests and skills, as well as the community in which programs have been developed in community he or she practices and the proximity to other medical hospitals, and there has been an increasing emphasis resources. Regardless of individual differences on university affiliations (Table 2). Some well bctween practices of family physicians, Stephens sug- developed networks of university-affiliated family- gests that "the sine qua non of family practice is the practice residency programs have been described,ro-tz knowledge and skill which allow the family physician and case studies of three well established graduate to confront relatively large numbers of un¡elected progranx¡ in family practicc have rccently been patients with unselected conditions and to carry on reported in some detail.rr therapeutic relationships with patients over time.', Jason has called for medical education to model Infusion of new arcas of knowledge and skills can be itself more directly on the needs of thc future phy- expectd to add to the academic discipline of family sician's practice.rl Th¿ s¿me premise has been ex- medicine ag rç¡earch efforts in the fìeld expand. pressed by Hodgkin in these words: "Teaching what (;E\'\I,,\\ Vol. 298 No. ll FAIVIIL\' PRACTIC¡- IN EVOLLITION -
Contenl ol Cu¡rlculum Brief reference has already been made to the con- tent of undergraduate curriculum. At the qraduate level, considerable variation in curriculum \t'as initial- developing family-practice u) ly demonstrated among g However, differences'among o residency programs. z programs are now decreasing as further experience i¡J o has been gained in program and curriculum develop- -fn l¡J Table 3 represents the curriculum in a (r ment. "typical" residency program today. and is consistent ou- with criteria and guidelines currestly in use by the (r Review Committee for Family Practice as t¡J Residency (f) well as the Residency Assistance Program, a national zf program with broad sponsorship described below. Over a three-year period, the familv-practice residency program invariably involves teaching rota- tions of about one year in internal medicine (including such medical electives as cardiology, neurology and dermatology), six months of pediatrics, four to six r969 70 71 72 73 74 75 76 JULY JULY JULY JULY JULY JULT JULY JULY Table 2. Types ol Family-Practice Residencies.* Figure L Total Number of Approved Residency Programs in Family Practice in the Unitecl States, According to Year No. oF PRocR^us (Based on Data Provided by the Division of Educat¡on' Àmerican Academy of Family Physicians, Kansas City, Mis- University affiliated 195 souri). Community-hospital based 58 University based 52 Military-hospital based 16 Toral 321
of Physicrans, is unrelated to the facts of practice tends to be un- 'Þata, providcd by Div¡sioî of Educatron, Amcri€n Acadcm! Famrly Con- Kansas City, MO, ¡eptænt all approvcd & opcratlonal progtams ¡n the U¡rled stales ås realistic and easily deteriorates into dogma."'s of August, 1977; 4 of the approvcd programs wcrc lot yct oPctattonal on that dale siderable progress has been made in many family- practice residency programs in this direction. At the Medical College of Virginia, for example, the proñles months of obstetrics-gynecology, six months of sur- of teaching practices in the several affiliated residen- gery and its subspecialties (incluciing ophthalmologl', cy programs have been documented to be nearly iden- orthopedics, otolaryngology and urology), t\,vo tical to those of nonteaching practices elsewhere in months of emergency medicine and one month of psy- Virginia.'6 chiatry (plus a strong thread of behavioral-science teaching presented longitudinally over the three-year program). Rotations during the second and third years involve progressive resident responsibility over first-year experience. The family-practice cente r provides the resident with an opportunity to care for an increasing number of families on a continuity basis U) Fz over a three-year period, and adds to his or her learn- oUJ ing and synthesis of knowledge and skiìIs derived from tf, residency program. t¡J(r other parts of the a L The resident's experience and training over three- year period represents that derived from the care of æ lll teaching practice (iamily- @ his or her patients in the inpatients, l practice center), as both outPatients and 2 ànd that derived from other parts of the residency program, such as inpatient rotations on other services ànd ambulatory experiences in other specialty clinics or community settings. Considerable emphasis has been placed on evaluation of resident experience and t969 70 7t 72 73 74 75 76 77 7A perfoimance on a competency basis in most famil,v- residencies. Several kinds of evaluation Figure 2. Total Number of Residênts in Approved Family- þractice methods have been reported that provide specific and Practice Residency Programs in the Un¡ted Ststes, Ac' ri-re cording to Year (Data from Same Source as Figure 1). individualized descriptions ol resident experience. OF MEDICINÐ March tó, 1978 59ó TllE NEW ENGLAND JOURNAL
The answer to this Fsmily-Prrctlcs sugtained among medical students' Tabla 3. Curriculum ln e "Typieal" the afhr- RealdencY' in the"late 1970's is srcngiy in ;;;*; in |.- åatiue. The percentage of first-year ,positions suBJ¡cf lÈtlnsn F^sLY-Pr cnæ programs in the United States that is n ffiaïoNr CEtrßr f"*ily-ptuctice ntt.¿'it now 94þ.it.nt (virtually-all resideqts being H&Y/*t' for the 2183 m l.u-Ju"r"* of American me
Table 5. Practice Arrangern€nts of 1977 Graduating Residents.r lVle¡oa Issuas Toner Excellent progress has been made during the first TlÆ or AluNoBxÊm . No. or Cle¡u¡f¡s PETCEM^GÊ oF ToT^! phase of family-practice development, and ãll the ini- Frmily-practicc group 268 38.ó tial issues have been effectively addressed. However, it Multispccialry group 80 I 1.5 is ciear that the development of any specialty is a long- ?-pcnon family- l4ó 2l.0 pråctiæ psrtncr¡hip term evolutionary process, and that some cf the im- Solo il7 ió.9 portant needs of a specialty cannot be met until some Emergørcy room 32 4.6 of the rnore pressing initial organizational efforts have Hospital stafl (full-timc) 30 4.3 (Ither 2t 3.0 been compÌeted. Indeed, tliis situation obtains in Totals 6% tm family practice, and the important issues today are somewhat ffipilEd by Divüon of Eduqrjor, physroans, different from those in the late 19ó0's. -_ 'D¡t¡, AEøien Aed.my of F¡mily Kuu City, i{O, ¡rc b¡rad on a óE% mponsc rarc from ¡ suney of t9i.l gr"au"ro. Perhaps the most pressing issues today are the follow- Tte sglì! æ quire ¡imilu !o Ëulß of carl.r surysys of l9?5 e. 1976 r6idcnr Endutã. ing; How can the reseârch base in family practice be established? How can the quality of teaching programs in family practice be assured? To what ex- Organlratlonel Drvelopmenl tent can tomorrow's family Ohysician deal with the lamily, not just the individual patient, as the object of The progress demonstrated during the last decade care? And how can the future practices ofgraduates of in educational aspects of family practlce has been as- family-practice residencies be organized for sociated with concu¡'rent growth and development of best use of their training and best mect the needs various organizations relating to the specialiT. to of their patients and communities? The American Board of Family' practice, es_ tablished in 1969, is the first certifying board in medicine to require recertification by eiamination. Rceoareh Base ln Famlly Hcdlclno The ñrst recerrification examinarion wâs held in 1g76, There is a wide specuum of irnportant ¡esearch with over 1400 diplomates taking the examination, needed in family medicine, which is quite different which includes cognitive testing arwell as audit of ac- from traditional biomedical research. Three broad tual patient records. Since ß7A over i 1,000 areas of needed research pertain to clinical strategies, diplomates have been certil¡ed in family practice. health-carc services and educational methods. On a The Ame¡ican phyiicians, Academy of Family sec- patient-care level, the family physician has several in- ond in size only to tt¡e American Medicai Association herent advantages relating to research: contact with among medical organizations in the United States, is all members of the family of all ages and both sexes; the major organization representing family practice direct experience with primary care of unselected through liaison with other medicãl organizations, patients; opportunity for long-term follow-up observa- government and other groups. The .A,cademy has tion of patients; multidisciplinary approach to care; played an im_portant part in the development of family and contact with patients in all stages of disease. The practice to date through a range of efforts inctuding family physician, therefore, has a wider perspective of faculty development, consultãtion to educationa'Í heaith and disease on the community lével than programs, collaborative clinical investigarion, anyone else in medicine. postgraduate education and related organizatiolal ac- Much of the rnedical literature to date has been tivities. derived from the study of patients admitted to univer- The Society of Teacl¡ers of Farnily Medicine was es- sity hospitais, who represent only one out of 250 tablished in 1968 as an academic organization con- patients seen by physicians and one out of 1000 ccrned primariìy with the development and improve- patients at risk each rronth.zt Since 90 to 95 per rnent cent of teaching skills in family medicine. Wlth of all doctor-patient contacts occur at the primary- mernbership " of over 1300, including family physicians care level,22 famiiy medicine has both the opportuniiy as w.ell as qlh-er disciplines involved in the tLaching of and the responsibility to add to knowledgè of health flmily medicine, this group is engaged in such ãc- and disease frorn the unique perspective of the family tivities as faculty development, cuiriculum develop- physician. ment and evaluation and research. Although scattered reports of noteworthy research The North American Primary Care Research in family practice have been published in recent years, Group is a small vigorouu but gioup developed to the over-riding priority in the specialty to date has in- promote research in the severai primary-caie dis_ volved the and development of teaching ciplines in the _o-rganization United States and ianada. By *.a.,, prograrns. Visible and respected examples of researcñ of annual pestin$ devoted exclusively to the prcsen- programs and researchers have tation and not yet been critique of original work, this gioup is in mosr family-practice settings concerned lgvglopqd in the with the development of researðt¡ sL¡lts United States. This deficit has been acceniuated and mæhods by in this hitherto neglected area of re- the la-ck of experience and skills in research ¡ea¡rh. among most family-practice faculty and practitioners. THE NEW ENGLAND JOURNAL OF MEDICINE March 16, 1978
The attitude of ge neral practice in the past and, to a perienced family-practice educators have developed considerable extent, ol family practice today has specific guidelines for quality in family-practice placed emphasis and highest value on the reduction of residency programs, including such factors as clinical knor.r'ledge and skills to'practical dimensions faculty/resident ratios, curriculum, evaluation thal are readily' understandable and recallable. This procedures and related areas. This program in- approach has often seen research as lacking relevance volves tw'o-day in-depth consultation visits by expe- to everyday clinical practice. Such an attitude has fre- rienced family-practice faculty to residency pro- quentlv been reinforced, during the family physician's grams requesting assessment and consultation.2e Over medical education, by his reaction to research ac- 100 consultation visits have already been con- tivities in other disciplines involving esoteric condi- ducted. tions and complex pathophysiologic mechanisms, not The rapid growth of famiiy-practice residency perceived as directly applicable to the work of the programs has prompted some observers correctly to farnily physician. Within family practice a new at- voice concern over quality control of these titude of critical inquiry must be developed that sees programs.3o'rt Although everyone can agree with the the importance and relevance of research within the over-riding importance of "quality" in educational developing specialty, itself. programs, there is less agreement on what this word There is some recent evidence that the relative lack means. Some equate quality with university-hospital of research in family practice will be corrected within settings and wonder how achievable it is in com- the next few years. Some of the basic tools are receiv- munity settings. Others defìne quality by the number ing general application, including the problem- of full-time faculty members involved in a program, oriented medical record. coding systems, data- the size of the hospital involved, the amount of time retrieval systems and active audit programs. Increas- devoted to a curricular area or other, related aspects ing collaboration is occurring among family-practice of a teaching program. The definition of a "quality settings and with other disciplines, including other education" appears to be as elusive as previous at- clinical specialties, epidemiology, social science and tempts to delìne the "good physician." biostatistics. A fellowship program intended to The essential flrst step toward measurement of develop research skills for future family-practice quality is to recognize the Ìimits of current definitions faculty has been established by the Robert Wood and the complexity of the problem. The measurement Johnson Foundation. Some conceptuai and of quality in a teaching program is a complex process methodologic papers dealing with family-practice that involves, for the individual resident, lour basic research have been published,?3-2t and case studies of categories: skills, competence, perlormance and out- three active departmental research programs have comes.32 In this context, such simple yardsticks as the recentiy been described in some ciepth.2t size of a teaching hospital or the number of full-time faculty members may not have any bearing on the learning, performance or effectiveness of care of an in- Thus, a resident in a Ouellty ol Teachlng Programr dividual resident in training. 200-bed hospital with a family-practice residency and The relatively rapid development of many new un- no other house staff may develop greater competence dergraduate and graduate teaching programs in fami- and provide better care than an equally well ly practice, together with the decenralization of many motivated resident in a 400-bed hospitai with a larger of these activities, has called for concurrent develop- full-time faculty and sizable house staff in other ment of effective evaluation and quaiity-conrol specialties. The variables in quality of a teaching mechanisms. This approach has been recognized as program are numerous, and include such dimensions an important priority in the field, and substantial ef- as varied resident needs, motivation and learning forts have already been mounted in this regard. These styles, spectrum of clinical exposure, responsibility for efforts include such areas as program review, ac- patient care, enthusiasm and qualifications of faculty, creditation, teacher development, competency objec- whether full-time, part-time or volunteer, and many tives and audit. Accreditation requirements for other elements. Quality should probably be viewed as family-practice residencies have been increasingly for- a constant process of improvement requiring con- malized in recent years, and between 40 and 50 per tinued self-assessment. cent of new applications for residency pnograms are disapproved by the Residency Review Committee for Family Practice. An intensive method of program Frmlly .s the Obl€ct ol Care review, the Residency Assistance Program, has recently been funded by the W. K. Kellogg Founda- The importance of the family as the object of care tion and implemented through the joint sponsorship has been well docume¡1sd.rr'r0 It is axiomatic that the of the American Board of Family Practice, the specialty of family practice is involved in the com- American Academy of Family Physicians and the prehensive, ongoing care of individual patients and Society of Teachers of Family Medicine. Over 30 ex- their families, and that the knowledge and skills re- j!'W'tt:¿¿x * a l¡¿il¡¡¿r¡.' "&i&¿it'¡L ¿¿;'ì:tí -
EVOLLÎTION _ GEYMAN \-ol. 298 No. l l FAMILY PRACTICE I}i
Futurs Fno¡ncnoxs quired by'the family physician include a broad range of clinical competencies' It is likewise axiomatic that of care in family practice, the familv is the basic unit Prtllnt C¡ra but herein is involved a profound concePtual shift ex- family physician]s practice well beyond thã care of the "whole patient" The prohle of the future tending to the individual physi- the care of tire family' not just thc individual, as will vary ssmewhat according to geographic setting of the the patient. Although this point is part-of the every- cian's interests, training and - dcveloping discipline of practice in terms of ñeeds ãf the community and day language of the . likeiy that actual (even in available medical resources. However, it is family .t-.di.in., Practic€ -teaching of family physi- progiams) stil¡ reflects a predominant focus on the similarities among the practices their differences' ih.-i.rdiuidnal, rather than the family, as the object cians will be far greater than studies have shown that the of care. A number of ricent provides dehnitive care Family-practice teaching throughout the well trained family physician Programs of problems en- country'håve placed varying degrees of emphasis on lor at least 95 per cent Patient-care practice'3tao It can be an- behaviäral science as a curricular approach to this countered in éveryday phys-icians will assume a The development of a strong teaching ef' ticipated that future family general area. both in and out of the iort in behavioral science, however, does not assure broad role in patient care, of preliminary (unpublished) the family as a unit becomes the object of care' As fræfi,.f. On the basis that of Iamily-practic.e Carmichael has noted, caring for the patient in the ..pt.tt of practice patterns some of the country, it context of the family is by no means the same as turn- t.åid.tt"y gr;duates in Parts- of. family physicians ing the family into the object of care.tT A concep- can be e*p"e.tea that a majority in their practices' Family physi- tuál thift is needed, together with more effective *ltt inctud. obstetrics be well grounded in diagnostic methods, to deal better with the family as cians must necessarily clinical and must assume in- a unit. and therapeutic alternatives creasing råponsibility for allocation of health services i"t iir.liputients in wirat is certain to become an era of limits. Cinsultation and referral will usually involv.e Futura Pr¡ctc¡r Organlzatlon ol lhe subspecialties; frequently, this situation will entail family physician.on a shared Family-practice teaching programs' particularly at contittlittg role of tÉe " wiTh the family physician the resiáency level, have ãlready made remarkable basis with füe consultant, provide general-medical care for the progress in ihe development of new approaches to continuing to 'records, for the family and the consul- care, medical audit, data-retrieval patient arid coùnseling þ"tii."t problem (or problems) re' systems and methods of practice managemcnt' iant managing the spãcific programs have quiring consultation. iraduates of tamily'practice residency ' that the future family wide range of ciinical competencies as.a result of Sonie have proposed a physician conline his or her their hospiial and ambulatory-based training' [t. is physician/primary-care or eiclusively to the ambulatory- therefore lmPortant that their transition into practice þrá.tic. principaliy 'care in a triage role as the entry allow their äapabilities to be eflectively used in the setting while åerving system''l'a2 Such an approach, care of their pätients and families, both in their oflice pÀittt to thã health'care judgment, would in the long-run cornpromise practice and in the hosPital. it *y - comPetence of these phys-ic-ig¡ residents require some exPosure to- the coritinüed clinical Family-practice primary care of high- in the community as a part of and their ability to prouide actual piactice settings Thè sharp seParation of Each program likewise has- the obliga- q"atity to their patiints. their tåining. community-orientid ambulato- evaluate new aPProaches to Prac- å"di"ät careers into tion to develop and care of acutely ill to practice (nonteachin-g) ry .".. and hospital-based intensive tice in t..*, of .*portability problems for both For exámple, effective rnethods of family p'"tit"tt *ould involve serious settings. -maintenance' 'medical education' The creation health education practice and medical .ounräli.rg, Pâtient discontinuity between am- and tcam practice rcquire testing within the con- of a sysæm with built-in and hospital care could be expected sraints of community-based Practice. U,rtatJ.y Patient of care, its cost' Family-practice residents must become skilled in, to jeopârdize thè quality -increase and depers.onalize care to, ongoing habits of audit and self- d.ðt.át. patient compliance attd committed possible that the for both ambulatoly and hospital-based f,r"ttt.t. Atttro,rgtr it ii theoretically assessment, could transmit all neces- departments of family practice must ambulatory-carã physician care. Clinical hospital-based in õommunity hospitals and assume an sary medical information to the Physi- become active hospitalized this effective role in monitoring of quality of care and ciaí rcgarding each Patient, to happcn.in everyday delineation of hospital priviÈges in collaboration with pio"-a,ti. *o,rid not be likeiy probable hospital care would deþartments. Hospital privileges must Lractice. It is more ihat other specialty medical problems t basid upon thc individual physician's previous Ë.- f"tttt.. overutiliåed, important be and procedures training and demonstrated comPetence. overlooked, unnecessary studies Per' THE NE\{ ENGLAND JOURNAL OF MEDICINE March 16, 1978 formed, and the pstient further confused by an en- creasingly accessible to and used by practicing family counter with an unknown physician at a time of major physicians. personaì crisis. Although research on the effect ofcon- of c4re is still embryonic, studies already iinuity Rc¡crrch reported indicate that costs of medical care, as well as in the luture piticnt satisfaction and compliance, are adversely af- Perhaps the most exciting dimension rese arch. An excel' lected by lack of physician continuity.as{5 of family practice lies in the area of Most family physicians in the future are likely to lent example of the Potential for research in this field practice in groups that serve populations of at least is the statewide study of the content of family Practice progress 5000 to 6000. The most common tyPe of group will completed last year in Virginia'¡6 As further probably bc the single-specialty group, but a variety is made in family-practice development, particularly and oPpor- óf group arrangemcnts will probably develop' Team- in educational programs, the capability practice will undoubtedly include various mixes of tunity to carry out needed research in family medicine be anticipated that nonphysician health professionals, but it is still uncer- will continually increase. It can will become more tain-what types of "teams" will stand the test of time the necessary tools for research data-retrieval systems' and experiencc. generally available, including ãudit, library'services and assistance with design and analysis of research studies. Among the many exam' Educdon ptes'of important research areas are the following: of health maintenance and preven' Eilucational efiorts in family Practice will be õost effectiveness diagnostic and thera- directed to the continuum ofundergraduate, graduate tive procedures; effectiveness of and continuing medical education. At the un- peutic methods; longitudinal audit of selected clinical care; content of dergraduate lcvel, further rcltnement and develop-- þroblems; functional outcomes of ment of curricula can be ânticipated in cach year of lamily practice in different settings; and effectiveness various learning levels. the mcdical-school curriculum. Family has of educational approaches at Practice continue to much to contribute to undergraduate education in As research methods and faculty skills research, it can be an- such areas as the natural history of common illnesses, improve in family-practice will move past preventive medicine, community medicine, the in- ticipated that original work in the field phase more sophisticated legration of behasioral science with clinical medicine its þresent descriptive to studies using case'control and and relatcd arc¿¡. predictive and causal of clinical At the graduate level, continued expansion of ðohort methods. The study and reporting experience through the unique perspective of the fami- rcsidency pxísitions in family practice will be required' and needed con- One impo*ant trcnd will be the increased develop- ly physician should make a r,aluable to primary care ment of regional networks linking medical schools tribution to medicine in general, and with affïliated residency programs in community in particular. hoepitals. The network bcing developed at the Univer- sity of Washington, a PrototyPe for this trend, in- DrscussroN efforts in curriculum develop- cludes collaborative Lynn recently observed that the public demands rharing teaching nesou¡ces' ment, evaluation, of ready access to family physicians who can provide and research.t? Another impor- faculty developrrrnt primary care for the large majority of illnesses, t¿nt t¡end will probably be the increasing develop' provide expert referral when indicated and serve as agreements concerning cur- -health-care ment of intertpecialty and general counselors for patients and ricular approaches to rpecific clinical competencies their families: required by family physicians. An excellent example of this method is the rccent agreement concluded This role has been present in society in times past, and it ap- bctween obstetrics-gynecology and family practice pears to be a reasonable assumption that the demand fo¡ this role known as the Recommended Core will continue. The current emphasis on family practice stemmed "ACOG-AAFP was not being well served, Privileges of Ob' from a public perception that this role Curriculum and Hoopital Practice which rcsulted in political and economic forccs being brought to stetricrÆynecology for Family Physicians''¡ó bcar to cor¡ect this situation.{t At the level of continuing medical education, with long interest and experience in scveral ímportant approaches are already in operation As a sociologist annual educ¡tional requirements of 50 hours the study of the medical profession, Frcidson made pcr- yea¡ by thc American Academy of Family Physi' the following observations in 1970: cians, rccertification requirements every rix years by l{ith the dccline of the gencral practitioner, the layman has tåe Amerícan Boârd of Family Practice, increased had lcss and le¡s chance to gain rtsponsiveness from profcssionals empharis en ¡udit in family practice and increased to his own vicws. And as the state comes to intcrvene more and and formal as to be physicians in various tyPes of mort a state which has bccome so large involvement of family rather -distant from the lives of its citizens, and whose notions of teaching programs. It c¡n be projected that teaching the individual public good are guided largely by profcssionals - and ¡elf-a¡sessment materials that are developed in li¡ent hãs evcn lcis opponunity to exPrcss and gain his own cnds' family-practíce æridency programs will bccome in- Some way of rtdrcssing the balance must bc found''r Vol 298 No. I t FAMILY PRACTTCE IN EVOLUTION _ GEYMAN ó01
There is ample evidenc€ that family practice is ef- t2. Geyman JP, Dcishe¡ JB, Cordon MJ: A rcgional nctwork of family prairicc rcsidcncy programs in thc Pacific Nonhycst. JAMA (in pressj fectively developing as a major response to these needs ¡3. Lcaman TL, Geyman JP, Brown TC: Graduatc cducation in famìly of the public in the United States. This development is practice. J Fa¡n Pract 5:47-61, 1977 an important part ofan accepted national goal to have 14. Jason H: Thc rclcvanct of mcdicsl cducation to mcdical practicc. I AM A, 212:2092-2095, 1970 over 50 per cent of American medical graduates enter t5. Hodgkin K: Educational implications of thc Virginia stud¡ J Fam one of the primary-care specialties. Since this goal re- Pract 3:31-14, 1976 quires over 7500 graduates enter first-year I6. Marsland DW, Wood M, Mayo F: A dst¡ bank fo¡ paticnt ca¡e, cur- to riculum and rcsc¿rch in family practicc 52ó, 196 patient problems. J residency positions in these specialties each year, each F¿m Pract 3:25-28. 38-6E, 1976 primary-care specialty must join in this effort. Peters- l7 Froom J, Culpepper L, Boisscau V: An integrâted mcdical reco¡d and darå systÊm for primary carc. lll, The diagnostic inde¡ - manuaì and dorf has noted the existing surleit of physicians in æmputer methods and applications. J Fam Pract 5:l l3-120, 1977 most specialties other than primary care, as well as 18. Molineux J, Hcnncn BK, MclVhinncy lR: In-training pcrformance as- the diflìculty pediatrics expanding scssmênt in family practicc. J Fam hact 3:¡105{O8, 197ó that has in 19. Tindall HL, Hcndcrson RA, Colc AF: Evaluating family practiæ rcsi- residency positions owing to a limited number of dcnts with a problem c¿lÊgory index. J Fam P¡act 2:353-358, 1975 patients on teaching seryices.s'{e Continued expan- 20. Longcnccko DP, Wright JC, Gillcn JC: Profilc of full-time family prac- ticc €ducators. J Fam Pract 4:lll-112,1977 sion of opportunities for residency training in both 2t. Whitc KL, \#illiams TF, Grccnberg BG: Thc ccology of mcdical carc. family practice and general internal medicine is N Engl J Mcd 2ó5:885-892, 196l therefore critical to meeting national needs for 7) Haggcny RJ: Thc univcrsity and primrry mcdical carc. N Engl J Mcd 281:416422, 1969 primary care. 23. McWhinney IR: Rcsca¡ch implicationr of the Virginia sludy. J Fam It is clear that the American hcalth-care system is Pract 3:35-3é, 1976 under heavy fire for its high cost, fragmentation and 24. Geyman JP: Rcscsrch ín tbc family practicc rcsidency. J Fam Prscl 5:245-248, 197'l potential depersonalization of sen¡ices, Public expec- 25. He¿bachcr P, Rickcl¡ K, Zamortico B, et al: A collabor¡tivc rc¡ca¡ch tations of rnedicine may well be unrealistic in many modcl in family praaicc. J Fam hgct 4:92!-921, 1971 26. probl€m in primary care respects, but the pressures change Bass M: Approachcs to thc dcnomi¡ator to the system in an rrscarch. J Fam Prast 3:191¡95, 197ó attempt better to meet the perceived needs of the 77. Schnccwciss R, Stuart HW Jr, Froom J, ct sl: A convcrsion c¿de from public have become strong. The genesis and develop- ihe RCCP to thc ICHPPC classihc¿t¡on systÈm. J Fs¡o Pr¿ct 5:415-d24. t977 ment of family practice have not occurred in a 28, lvood M, Stcvsn rP, B¡o¡rn TC: Rcecsrch in family mcdicinc. J Fam vacuum, but as a logical part of a larger sociocultural P¡act 5:ó2-88, 1977 evolutionary process. 29. St¿rn TL, Chaisson GM: Thc residency assistsncc program in family prsctice. J Fam Pract 5:379-3E1, 1977 The challenge now before medicine is to play an ac- 30. Pctc¡sdorf RG: Intsrnal mcdicinc and family prectic.: c¿ntrovcrsics, tive part in the reassessment and remodeling of the conflicr and compromisc. N Eugl J l¡{á 293:32G332, 1975 31. Family precticc: quelity eod srÊdibility. N Engl J Mcd health-care system to €xtend the highest possible Keith JF: ?97:.tW7-lffi, t977 quality of care to the entire population at a cost that 32. Fclch WC: Thc continuur¡ of mdical cducation. AHME J E(3): I, l9?5' can be afforded in a society that may not be able to ex- 76 pend a larger portion ol its gross national product on 33. Curry HB: Thc family u our prtiont. J Frtr¡ Prsct l:70, l9?4 v. Baum¿n MH, Graæ NT: Family proess and family Practicc. J Fsm health care. The continued successful development of P¡zcr. l:2*26,1971 family practice as a foundation of primary care in the 35. Gcyman JR Thc f¡mily ar the objccr of csrc in femily practicc. J Fam United States is an Pract 5:571-575, 197? important part of this remodeling 36. Rakcl RE: Impact of illnc*s on the family, Principlcs of Family process, and represents an effective response to ex- Medicine. Philadclphia, rilB S¿unden, 1977, pp 342-366 isting and projected defìcits in primary care. 37. C¡rmichael LP: Thc family in mcdicine, proccss or cntity? J Fem Pract 3:562-563, 1976 3t. Schmidt DD: Rcfcrål p¡ttcrrr in ¡a individu¿l family practicc. J Fam Rrr¡rr,NcEs Prqcr 5:,101-403, 1977 39. Geyman JP, Bro*n TC, Rivcrc K: Rcfcrals in family practicc: a com- l. Citizcns Commission on Grsduatc Mcdical Educetion: Thc Graduaæ parôtivc ¡tudy by gcqraphic rcgio¡ snd procticc sctting. J Fam Pract Education of Physicians- Chicego, Americ¿¡ Mcdical Asrociation, 3:ló3-167,1976 r9óó ¿fO. Mctcalfc DHll, Sischy D: Pattcrn¡ of refcrrcl from family precticr. J 2. Meeting thc Challcngc of Family Practicc: Thc rcport of the Ad Hoc Fam Pract I:34-38, 1974 Committcc on Educâtion for Family Praaicc of thc Council on 41. Pctcndorf RG: Issues in primary care thc acadønic perepoctivc. J Mcd Medical Education. Chicago, Amcricsn Medicål Association, 19óó Educ 50:5-13, 1975 3. National Commissioo on Community He¡lth Serviccs: He¡lth i¡ e 42. Progcr S: A c¡¡ccr in embulatory mcdicinc. N End J Mcd 292:1318- Community Affair. Cambrid¿e, Harvard University P¡css, 1966 t324, l97S 4. Sæphens GG: Reform in thc Unircd SiåtÈr: ítr impact on medicinc end 43. Alpcrt JJ, Kora J, H¡ggcrty RJ, rt ¡l: Attitudcs and satisfactions of cducation for family pracricc. J Fsm Prsc.t 3:507-512,1976 low.income familics rccciving comprchensivc pcdiet¡ic c¡rs. Am J 5. Mclilhinncy lR: Gcnc¡al practicc at ¡,¡ rc¡dcmic dirciplinc. Lancct Public Hcslth 6û499-$ó, l9?0 l:419423,19f6 Hcagarty MC, Robert¡on LS, Kor¡ J, èt al: Somc comparative costs in ó. Ccyman JP: Family mcdicinc ¡¡ en ac¡dcmic diccipline. J Mcd Educ comprchcnsivc vcrsur fregmentcd pcdi¡tric c¡¡c. Fcdiatrics 46:596ó03, 4ó:815-820, l97l r970 7. Stephcns GC: Thc inrcllc.tual barir of family preaicc. J F¡m pr¡ct 45. Bcckc¡ MH, Draehma¡ RH, Kir¡cht JP lt licld cxpcrimcnt to cvaluate 2:123428, t975 various oul.comcs of continuity of phyaician ce¡e. Am J Publie He¡lth E. Barnat L: Carving an undcrgradurtc curriculso ia frmily prrrticc. J 6a:1062-1070, 1974 Fam Pract 4:861-863, 197? 46. Stcrn TL: A landmerk in intcnpccieþ cooperation. J Far¡ hecr 5:523- 9. Bakcr RM, McWhinney I, Bro*¡ TC: Uadc4ndurt? Gduc¡tioû in 5U, t977 family medicinc. J Fam Prsct 5:37,.46, 1977 17. Lynn TN: Thc futu¡c of family pndicc. Cootin Educ rìrm Physician 10. Wood M, Mayo F, Marrland D: A Byst€mr rpprorch ¡o psticnr cerc, 6:2*25, 1971 curriculum rnd rc¡c¡rch in family practicr. J Mod Edræ Sûl t06'l I12, ¡tt. F¡cid¡on E: Profc¡sion of Mcdicinc: A rrudy of thc sociology of ap t975 plicd knowlcdgc. Ncv York, Dodd, Mcad, 1970, p 352 ll. Gcyman JP, Brown TC: A nawork modcl for &ccntrelizcd femily 19. Pacndorf RG: Hcalth manpo*cc nunbcr¡, di¡tribution, quality. Ann praaicc reridcncy tr&ining. , F¡m PraA 3:671{'27,1976 lntcrn Med E2:69#?01, 1975