Specializing in the Family

The American family doctor of tomorrow will be more highly skilled than his predecessors, have more responsibilities, and boast a higher status. He will, that is, if medical educators and today's family doctors themselves have anything to say about it -- and in recent weeks they have been saying plenty.

The continuing talk reflects some embarrassing statistics. In 1931, no less than 84% of U.S. physicians called themselves general practitioners; today, their numbers have shrunk to 37% . Only 18% of this year's medical graduates expect to go into general practice. The G.P. has steadily lost both prestige and patients to medicine's fast-growing horde of specialists. In hospital after hospital he has lost the privilege of attending his patients, and in many hospitals he has even been denied his traditional right to perform routine surgery.

Like Quarterbacks. It is a situation that harms the G.P.'s patients as well as the G.P. himself. "What is wanted," said a Citizens Commission on Graduate Medical Education, set up by the A.M.A. and headed by Western Reserve University President John S. Millis, "is comprehensive and continuing health care," which must include not only diagnosis and treatment but also preventive medicine and rehabilitative care. "Few hospitals and few existing specialists consider comprehensive and continuing medical care to be their responsibility and within their range of competence," said the report, "and not many of the present general practitioners are qualified to fill this role."

The commission's prescription: a new medical specialty composed of "primary physicians"--so called because they would have first and continuing contact with the patient. Their training, said Dr. Millis, who is a physicist, not a physician, would involve abolition of the present system that calls for medical graduates to serve an internship of a year or more before going into practice. Future primary physicians, like candidates for all other medical specialties, would have to go into a three-year residency program immediately after graduation.

These suggestions drew enthusiastic support from the American Academy of General Practice, which met in Boston last weekend to consider its own report on "the core content" of what it calls "family" rather than "primary" medicine. The academy's leaders urged its members to "divorce themselves from the present and think in terms of the future," when the general practitioner turned family physician will be "a specialist in terms of the function he performs, not a specialist who treats only certain diseases or parts of the human body." The new family physician, said the academy, will see "illness and disease not only as biologic phenomena but as a possible outgrowth of emotional and environmental problems. Family medicine is a specialty in breadth rather than a specialty in depth."

"Applicable" Surgery. To give the future family physician that breadth, the academy proposes that his residency training include some psychiatry as well as surgery, pediatrics, gynecology, obstetrics and geriatrics. Whether the F.P. practices alone or in a partnership or in a group must be his decision, but the academy insists that he be allowed to perform "applicable" surgery --meaning major operations in remote areas, but only minor procedures such as tonsillectomies and routine repairs where specialists are at hand.

Perhaps most important, academy leaders said that F.P.s must continue postgraduate education all their lives. F.P.s, they said, should be certified as specialists in the same way that other specialty groups now certify their diplomates. Beyond that, the core report recommended that F.P.s should also be subjected to periodic re-examination--a tough requirement that no specialty group yet imposes. The congress of delegates of the A.A.G.P., which may soon change its name to A.A.F.P., unanimously adopted the core report.

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