The Americanization of Family Medicine:
Contradictions, Challenges, and Change, 1969-2000
Rosemary A. Stevens, PhD, MPH

Family practice became the 20th medical specialty in 1969, identified by its leaders as a harbinger of health care reform, as well as practice excellence, and with expectations of continuing government support of its purpose and role. Since that time, the cultural and political environments have changed significantly in some ways, and not changed in others as initially expected, thus challenging the new specialty with pressures for reinvention with respect to its identity, function, and prestige. The most important impediment to a clear-cut role for family practice has been the lack of a formal administrative structure for primary care practice on a nationwide basis in the United States. Differentiation of the field from all other parts of medicine was also difficult because of the identification of family practice with the professional accoutrements of a specialty, parallel to other specialist fields. Family practice moved from an outsider role in medicine to a position of entrenchment in the medical establishment, including hospitals and academic medical centers. And, family practice became one of several overlapping and competing primary care fields. The role of family practice in US culture is now less clear than the potential role envisioned for it in 1969. Its multiple and not always well-defined roles in medicine may make it difficult to establish a clear identity for the specialty in the future. If it is to be successful, family practice must develop allies and work aggressively to establish its role in primary care. It must also work to institute primary care in the US medical system and act politically (as in the 1960s), taking advantage of current cultural trends, notably the information revolution and the growth of biomedical research.
(Fam Med 2001;33(4):232-43.

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A Vow of Connectedness:
Views from the Road to Beaver's Farm
David Loxterkamp, MD

The doctor-patient relationship lies at the heart of family practice. Yet in a digital age, our understanding of this relationship has been trimmed to a transaction between free agents that can be fully measured and isolated in time. The vow of connectedness restores the broader view. We know that lasting change-in attitude and behavior, toward healing and hope-arises from those relationships that encompass the doctor, his or her patients, and our common connections in the communities we serve.
(Fam Med 2001;33(4):244-7.)\

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Family Practice and Social and Political Change
G. Gayle Stephens, MD

Reform in US medicine has been a longstanding process, and it has always been intertwined with politics and social issues. So-called organized medicine has often resisted reform, but despite this resistance, many changes took place in the US medical system in the 1960s. The establishment of the specialty of family practice coincided with these changes. Although family practice was established with many goals in mind, many of the goals did not match the public's perceived needs, and there is still much unfinished business. One of family practice's current tasks is to examine its accountability to the public and decide what it can provide for the public good.
(Fam Med 2001;33(4):248-51.)

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Is Where We Are Where We Were Going?
A Dialogue of Two Generations
Lynn Carmichael, MD; Susan Schooley, MD

This article provides the dialogue of a discussion between prominent family physicians from two generations. One, from the first generation of family physicians, was a founder of the specialty who provides insights into the origins of the specialty, its goals and aspirations, and possible future directions. The other, from a younger generation, has been a leader in managed care and its effects on family medicine; this physician discusses future changes in the health care systems and reflects on whether or not family practice will be able to adapt to those changes.
(Fam Med 2001;33(4):252-8.)

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What Does Family Practice Need to Do Next?
A Cross-generational View
John P. Geyman, MD; Erika Bliss, MD

Background and Objectives: This paper presents a 60-year view of family practice, including its first 30 years and best projections for its next 30 years as a discipline and field of practice. Methods: An objective cross-generational approach was taken based on available evidence. Results: Five lessons are drawn from the past 30 years: (1) Neither medical education, medical practice, nor the health care system have been reformed by family medicine. (2) Family practice remains but one of several options for primary care. (3) The generalist-specialist ratio has shifted farther to specialists since 1970. (4) The United States is unique among Western industrialized nations in having multiple generalist specialties. (5) The three primary care specialties are on parallel but separate courses. The health care system is now very different from that of 1970, as a result of managed care; increased burden of chronic illness in an aging population; de-emphasis of hospital care; proliferation of primary care providers; increased emphasis on shared decision making with patients, cost-effectiveness, and value of health care services; and advances in information and communication technology. Conclusions: The following course changes are recommended for family practice: (1) Embrace new paradigms of care (eg, evidence-based medicine, population-based care, chronic disease management). (2) Modify practice style and redesign systems of care. (3) Embrace further differentiation within family practice. (4) Reassess and revise educational programs at all levels. (5) Increase emphasis on practice-based research and expansion of clinical electronic databases. (6) Explore feasibility of a unified generalist discipline through new alliances with other primary care specialties. (7) Build organizational and political strength through alliances in advocating for structural change of the health care system to include universal coverage and a generalist primary care physician for all Americans.
(Fam Med 2001;33(4):259-67.)

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What Opportunities Have We Missed,
and What Bad Deals Have We Made?
Michael K. Magill, MD; William J. (Terry) Kane, MD

In addition to its many accomplishments, family medicine has inevitably made some choices that have not worked out as well. Respectful consideration of where we may have done so can help inform future decision making. This paper suggests some decisions that in retrospect appear to be bad deals, good deals gone bad, or missed opportunities. Bad deals include the limiting effects of our specialty's name and of our go-it-alone philosophy. Good deals gone bad include our affinity for a permanent counterculture role, our persistent belief that big is better, and limited evolution of our residency family practice centers. We have missed opportunities to lead development of a new model of patient-responsive health care, to change the system of payment for care, to maximize the strength of our discipline by links between university and community family physicians, and to build a powerful program of family medicine research.
(Fam Med 2001;33(4):268-72.)

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The Domain of Family Practice:
Scope, Role, and Function
William R. Phillips, MD, MPH; Deborah G. Haynes, MD

The family physician is the physician generalist who takes professional responsibility for the comprehensive care of unselected patients with undifferentiated problems and who is committed to the person regardless of age, gender, illness, or organ system. The clinical specialty of family practice is patient centered, evidence based, family focused, and problem oriented. Family physicians acquire and maintain a broad array of competencies that depend on the needs of the patients and communities they serve. The scope of their practice is not defined by diagnoses or procedures but by human needs. Family physicians do not treat diseases; they take care of people. Nodal points in the family life cycle, such as birth, serious illness, and the end of life, deserve special attention. Family physicians are expert at managing common complaints, recognizing important diseases, uncovering hidden conditions, and managing most acute and chronic illnesses. They emphasize health promotion and disease prevention. Their knowledge, skills, and attitudes target community practice, current science, and continuous quality improvement. Family practice has a distinct clinical approach that requires special skills to identify concerns, focus issues, negotiate plans, and help solve problems. The recognition, integration, and prioritization of multiple concerns and the synthesis of solutions are critical clinical competencies. The variety of human needs require targeting the clinical process, sharing responsibility, and managing uncertainty. Focus on the person requires refined abilities to observe, communicate, understand, and care. Commitment to patients and populations involves activism and advocacy. Family medicine can lead in redefining what it means to be a professional, a physician, and a generalist.
(Fam Med 2001;33(4):273-7.)

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How Does a Changing Country
Change Family Practice?
Jeannette E. South-Paul, MD; Kevin Grumbach, MD

The US population is changing. Ethnic minorities are now the fastest growing segment of the US population, and they have higher mortality rates than the remainder of Americans. Members of minority groups also earn less and are twice as likely as other residents to lack medical insurance. Minority communities have poorer health and access to care than the remainder of the population. Women constitute more than half the total population of the United States and are half of the labor force. Family structure has changed such that 53% of African-American, 32% of Hispanic, and 27% of all families were headed by a single parent in 1992. The elderly population has also increased and has a greater prevalence of chronic disease. The physician workforce has more female and younger physicians than in the past but a still-inadequate number of minority physicians. In contrast to the low proportion of minorities in the US physician workforce, women now comprise approximately half of medical students. A major economic trend affecting health care access in the United States is the lack of secure insurance coverage for 44 million people in 1998. Rates of no insurance are higher among minorities, households with no full-time worker, the near poor, and among persons with less education. Private charitable services, as well as the formal safety net systems, are experiencing financial pressure in the United States, further jeopardizing access to care for the uninsured. The average family in the United States is now working harder-but earning less money. The changing population mix, shifting gender balance, increasing proportion of elderly, and major socioeconomic trends and income disparities occurring in the United States today have shaped a practice environment that differs from what faced family physicians 30 years ago. Thus, a change in approach to training and practice is needed, while preserving the critical relationship we have with our patients and continuing to meet their needs.
(Fam Med 2001;33(4):278-85.)

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Developing the Knowledge Base of Family Practice
Kurt C. Stange, MD, PhD; William L. Miller, MD, MA; Ian McWhinney, OC, FPPC, FRCP

Borrowed and adapted knowledge is insufficient to optimize the potential of a comprehensive, integrative, relationship-centered generalist approach to improve the health of individuals, families, and communities. The knowledge base for family practice must be expanded by integrating multiple ways of knowing. This involves (1) self-reflective practice by clinicians, (2) involving the patient voice in generating research questions and interpreting data, (3) inquiry into the systems affecting health care, and (4) investigation of disease phenomena and treatment effects in patients over time. A multimethod, transdisciplinary, participatory approach is needed to create knowledge that retains connections with its meaning and context and therefore is readily translated into practice. This research integrates quantitative and qualitative traditions and involves the active participation of both clinicians and patients. The generation of relevant knowledge should be supported through (a) developing a culture of reflective practice among clinicians, (b) expanding the infrastructure for practice-based research, (c) developing a multimethod, transdisciplinary, participatory research paradigm, (d) longitudinal study of the process and outcomes of broad, integrative, relationship-centered care, and (e) incorporating pursuit of new knowledge as a central feature of training programs and policy. The time has come for the generalist disciplines to commit to the generation of new knowledge based on the needs of patients, families, and communities for relationship-centered, integrated, prioritized health care. Development of a culture of learning and inquiry and the necessary research methods and skills will require a long-term commitment, creation of partnerships, and a focus on core principles by individuals and organizations.
(Fam Med 2001;33(4):286-97.)

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How Will Family Physicians Care for the Patient
in the Context of Family and Community?
Lucy M. Candib, MD; Lillian Gelberg, MD, MSPH

Difficulties caring for patients in the context of family and community stem from problems of power and vulnerability. Patients are disempowered in relation to physicians and to the medical care system. Physicians are disempowered in their ability to provide comprehensive relationship-centered care to individuals and families because of economic constraints on medical care and limits on continuity of care. Individual patients are also vulnerable to abuses of power within their families because of physical and sexual abuse; the recognition of such abuses and appropriate interventions for them requires awareness of the gender ideology that underlies interpersonal abuses of power. Families and communities can be disempowered because of vulnerabilities related to race, ethnicity, poverty, and homelessness. The additive effects of these vulnerabilities have created health disparities that are a hallmark of inequities in our country's medical system. Opportunities to teach students to recognize and address these disparities abound within medical education. Participatory training and educational action projects can prepare learners to lead us toward a more just and egalitarian medical system with the potential to change the context of family and community in which we care for patients. However, systematic commitment from educational programs is necessary to produce activated clinicians, teachers, and researchers to achieve these changes.
(Fam Med 2001;33(4):298-310.)

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What Can Technology Do to, and for, Family Medicine?
Mark H. Ebell, MD, MS; Paul Frame, MD

Medical technology can be divided into information technology, diagnostic technology, and therapeutic technology. These technologies can enhance the care of patients in a family practice; they also have the potential to diminish or fragment family practice when the technologies can only be provided by specialists. While some family physicians have an aversion to technological advances, we believe it is imperative that family physicians participate in the development of technologies that enhance family practice and improve patient outcomes in primary care practice. These include electronic medical records, decision support systems, tools for managing medical information, and others. Criteria are presented to help determine when these new technologies should be adopted into practice.
(Fam Med 2001;33(4):311-9.)

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Family Practice Triumphs by the Year 2020:
What Will We Have Done Right?
Marjorie A. Bowman, MD, MPA

For family practice in the United States to be considered a success in the year 2020, several things will need to be done right between now and then. These include (1) an emphasis on quality of care, (2) a dependence on new technologies to enhance quality, (3) availability of and access to primary care for the entire US population, (4) increased political power for the specialty of family practice, (5) enhanced research and research funding, and (6) learning to work with patients so that they are the masters of their own care. If successful in 2020, family physicians will be perceived as quality physicians who use technology that everyone wants and who use their political power to advocate for patients' rights to quality health care and the research important to the discipline and quality health care. Family physicians will have become the "go-to doctors" who put patients in charge.
(Fam Med 2001;33(4):325-7.)

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