_ 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