A Specialty for Generalists: The Decline of General Practice and the Rise of Family Medicine
The field of Family Medicine officially came into existence only in 1969, an era of conflicting pressures on the medical profession when a demand for greater patient access to "continuing, comprehensive care"—that is, a demand for more primary care doctors—openly competed with a drive for more physician-scientists.(3) The first half of the twentieth century had been a "golden age" for American medicine, a time of higher educational standards, increasing specialization, technological advance and, especially, rising prestige. By World War II, specialists straight out of residency received higher rank and pay from the military than did even the most senior GPs. The development of astonishing drugs like penicillin, procedures like open heart surgery, and the deepening promise of molecular research, seemed to indicate that fulfilling the promise of modern medicine required a technically sophisticated, scientifically driven enterprise.(4)
Declining respect for the traditional "GP" was an unsurprising corollary to these developments. When in 1959 the United States Surgeon General called for a drastic and immediate increase in the number of physicians available for a growing population, general practice was hardly the model envisioned by the new federal mandates.
Cold War-era anxieties also raised the specter of doctors who could not "keep up" unless they were educated as specialists, perhaps even as scientists, in their methods and values. Both the National Institutes of Health (NIH) and the National Science Foundation (NSF) began to ramp up research funding after the War. Increased spending on new hospitals since passage of the Hill-Burton Hospital Survey and Construction Act of 1946 called for thousands more interns and residents, which translated into a call for more highly-trained specialists. Then, too, the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) both began to urge greater medical school oversight of residency education, emphasizing the need to define residency more as an educational activity and less as a low-paid service for hospitals; indirectly this encouraged an increasing emphasis on the academic and specialty-oriented nature of post-graduate education, and especially, the need to complete a residency and pass a specialty board's certification exam. Finally, most young physicians plainly preferred to specialize, a practice style which typically afforded contact with modern, well-equipped hospitals, intellectual excitement, and a sense of being part of the forward progress of one's profession.(5)
Between 1960 and 1982, forty-one new medical schools—including UMass Medical School—were built to remedy the perceived physician shortage. Pre-existing schools also increased their class sizes; in all, the number of medical graduates between 1960 and 1980 increased by more than 200 per cent. Little thought was given at first to the kinds of doctors these new graduates would—or should—become. Certainly, few would have predicted that within a decade of the Surgeon General's Report, the seemingly non-specialized field of Family Medicine would metamorphose as a board-certifying specialty. Nor would many have predicted that by 1975 the new specialty would play a significant part in public policy debates over medicine's "manpower" problems.(6)
Parallel trends, however, convinced health "manpower" planners that competent primary care doctors were just as essential for the public's health as high-tech specialists or lab-based researchers. The population increase of the post-World War II era, an increase resulting not only from the celebrated baby boom but also from the increased longevity of the population, played an important role in dictating the creation of a newer form of family doctor. With longevity came an increasing proportion of chronic or debilitative ailments, entailing new pressures on the health care system. The passage of Medicare and Medicaid in 1965 as part of a constellation of Great Society legislation definitively reshaped the national conversation about the public's need for doctors. Even those programs' massive infusion of health care dollars would not satisfy the national need unless more primary care physicians were factored into the health care mix. If most physicians, as we have seen, clustered near major medical centers or the larger hospitals serving affluent suburbs, communities either too poor or too far from such centers often lacked any health care provider at all. Rural towns especially lacked health care. In the words of the influential Millis Commission Report, The Graduate Education of Physicians (1966), which endorsed greater professionalizing of residency education but also issued a strong call for inclusion of primary care, "there are unrecognized and unmet needs [for] continuing, comprehensive care," which medical schools and residency programs should begin to address immediately.(7)