Family Medicine

A New Approach to Health Care

Betty E Cogswell, Marvin B Sussman

• Publisher: Routledge
• Year: 2014
• Print ISBN:
  9780917724251
• eBook ISBN:
  9781135893972
• Topic: Medicine
• Subtopic: Health Care Delivery

Here is an insightful review of the origins of family medicine as an AMA-approved specialty, including the difficulties in developing the role of family physician.

FAMILY PHYSICIAN: A NEW ROLE IN PROCESS OF DEVELOPMENT

Betty E. Cogswell, PhD

Dr. Cogswell is Associate Professor of Family Medicine at the University of North Carolina, Chapel Hill, NC 27514.

Introduction

Family physicians, the most recently recognized specialists in American medicine, are in the enigmatic situation of developing the occupational role which they simultaneously occupy. In 1969 the Council on Medical Education of the American Medical Association (AMA) formally approved family medicine as the 20th specialty. Both prior to and since this date the emergence of this new discipline has been heavily rooted in reforms to correct deficits in contemporary practices of patient care. Family physicians are dedicated to providing continuing, comprehensive, primary care to families. This approach is viewed as a corrective for the fragmented, episodic, highly bureaucratic, and technocratic care many patients now receive. Interwoven with family physicians’ reform efforts are their concerns with establishing a firm position of status, influence, and academic respectability within the institutional structure of medicine. These two issues—reform and family medicine’s position within medicine—have influenced and most likely will continue to influence the process of development of this new role.

This process of role development is more easily observed among academic physicians than among those in private practice. Academicians have taken leadership in attempting to conceptualize the nature of their field and to publish the results of these efforts. Their publications indicate that they have been continually assessing their role, codifying definitions, and taking cognizance of the changing position of their field within medicine. Academicians are also a source of role innovations which they in turn pass on through the educational process to future family physicians.

The paper is organized around two topics: the influence of reform and position on the development of the role of family physician, and the presentation of an analytic model which describes some components of this new role. My comments on the emergence of the role of family physicians and speculation as to its future course are framed within the sociological approach of symbolic interaction—a theoretical approach amenable to the study of role development (Note 1).

Theoretical Assumptions Underlying Role Development

Even roles which have matured and become institutionalized are never static, for there are always changes over time, however slight. In order to approximate reality, developing roles must be analyzed from a process rather than a static frame of reference. The majority of investigators have shown little concern with development of professions through time; they have instead viewed occupations and occupational roles as more or less static (Note 2). Some, however, have dealt with the processes by which occupations arise, take form, or change. A small portion of these investigators deal with roles of medical professionals (Smith, 1955; Bucher, 1962; Bucher & Strauss, 1961, 1968; Cogswell & Weir, 1964). Their studies focus on diversity and transformations within professional groups and the processes involved in their development.

Sociologists who analyze occupations as processes tend to have roots in the “Chicago” or symbolic interaction school of sociology (Note 3). This theoretical orientation leads one to focus on change over time, the variety of different perspectives within a profession, and the processes of continuous interactions which structure group life. Further, those who subscribe to this theoretical approach argue that highly structured human association is relatively infrequent and that institutionalized patterns constitute only a loose framework for daily behavior.

Particularly since the field of family medicine and the role of family physician are emergent, a symbolic interaction approach seems most appropriate as the basis for comment in this paper. Symbolic interaction points to the variety of perspectives among family physicians and individuals in other groups with whom family physicians continually interact and who together influence the definitional process. Processes of role definition proceed through family physicians’ interactions and negotiations with each other and with patients, physicians in other medical specialties, paraprofessionals, hospital administrators, deans of medical schools, officials in state and federal governments, and members of the public at large.

Role definitions of family physician vary considerably both among family physicians and among people with whom they interact. Some individuals, particularly other medical specialists, see family medicine as merely another name for general practice. For others, family medicine is synonymous with primary care. This second definition prevails among many specialists and perhaps with less frequency among some state and federal officials, deans of medical schools, and hospital administrators. Although all family physicians would agree that they give primary care, they usually augment this definition to include delivery of continuing and comprehensive care. A large proportion of family physicians further elaborate their role to include emphasis on personalized and humanized care. A smaller group adds a third component to their role: caring for families. The largest proportion who subscribe to this last notion refer to family physicians’ treating all members of a family. Others view patients within a family context where families are seen either as support groups for patients or as contributors to the etiology of disease. A few family physicians conceptualize families as small biosocial systems and consider this family system the proper unit of care. Among patient populations and the public at large, there are individuals who are likely to favor any one of the above definitions. Both the frequency and the degree to which family physicians and role relevant others subscribe to these definitions are matters for empirical research.

Family physicians speak of their specialty as one of breadth. They are generalists who primarily draw their scientific medicine and technical expertise from five older specialties—internal medicine, pediatrics, surgery, obstetrics-gynecology, and psychiatry-neurology. Compared to these specialties, family medicine is still a young field marked both by rapid expansion and by change, variety, ambiguity, and conflict in the images and definitions of the role of family physician. The reforms they champion require innovation; and, as has been pointed out, “Innovation … rests upon ambiguous, confused, not wholly defined situations” (Strauss, 1959, p. 26). It is in areas of ambiguity that transformations take place (Burke, 1945, p. 24) and new values and models for behavior emerge. Compared with older specialties, where roles are relatively static and their practitioners experience a rather quiet milieu, the definitional process of a new medical specialty is filled with exciting and dangerous experiences (Strauss, 1959, p. 144). Individual and collective actions by family physicians are still tentative and exploratory, and it is likely that both the ends of and the means to role development will be reformulated as the role evolves.

Influence of Reform and Position on Role Development

A growing awareness of the need for reforms in patient care has stemmed from two major sources: the medical profession itself and critics in the society at large. Family physicians have addressed reforms as a basis for establishing a new specialty and for determining the goals for role development. At this point, family physicians are better able to articulate what they want to improve in the present system of medical care than to state the exact nature of their specialty and the means by which they hope to correct these deficits. The desire to attain a respected and influential position within the field of medicine also influences family physicians’ image of their role, the nature of their reform efforts, and the speed with which these reforms can be implemented within their own specialty.

The Need for a Reform Movement in Patient Care

The reaction of the medical profession to the Flexner Report published in 1910 and the resulting reorganization of medical education which led to a proliferation of medical specialties in the following decades are often cited as the causes of the need for reforms in medicine today. Prior to this report, most of the physicians in the United States were general practitioners who provided the majority, if not all, of the care for their patients, seeing them on a continuing basis as needed over a lifetime (Note 4).

The general practitioner of revered memory knew his patients, did whatever he could to cure or ease their varied ailments, and provided continuing care through the course of minor ailments and major emergencies. His deficiencies—and they were many—were partly offset by intimate knowledge of his patients, the support he gave them, and the trust and confidences his services engendered (Millis, 1966, p. 33).

Concerned about the quality of care and the inadequacy of medical training, Flexner advocated higher standards and longer periods of graduate training. Eventually, medical schools and residency programs graduated more specialists and fewer physicians trained for primary care. Specialists tended to locate their practices in urban medical centers where they could have access to advanced technology, supportive services, and consultations from other specialists. As a result, rural areas were underserved and patient care became highly bureaucratic, technocratic, fragmented, and episodic. Family medicine is a response both to correcting these deficiencies and preserving the assets of general practitioners: a 3-year residency program provides a more adequate grounding in scientific medicine than general practitioners receive, and reforms in the delivery of patient care correct for medicine’s overreaction to the Flexner report.

Awareness within medicine of need for reform. In the 1960s some segments within the medical establishment became concerned about medicine’s neglect of quality primary care and recognized the need for establishing a primary care specialty with a solid position in institutionalized medicine and medical education. In 1966 three separate blue ribbon commissions published reports which ushered in family medicine, charting a course for its formal establishment and launching it on a mission of reform [The Graduate Education of Physicians: The Report of the Citizens’ Commission on Graduate Medical Education (The Millis Report); Health Services (The Folsom Report); Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for Family Practice (The Willard Report).] The authors of all three reports speak of the need in American medicine to overcome barriers to providing continuing and comprehensive patient care, and they express concern about geographic maldistribution of physicians and the decreasing ratio of primary care physicians to medical specialists. In each report there is a strong affirmation that individuals and families throughout the country should have easy access to personal physicians oriented toward the whole person and providing both scientific medicine and humanistic care.

Societal criticisms of established medicine. Family medicine originated and has continued to grow during a period of social unrest in which there has been a growing disenchantment with and a call for reform of the established system of medical care. Criticisms have come from many sources and have taken a variety of forms, ranging from radical indictments to more moderate but critical appraisals. Ivan Illich (1975), in a sweeping accusation, begins Medical Nemesis with the sentence, “The medical establishment has become a major threat to health” (p. 11). Illich goes on to describe iatrogenesis (physician/hospital-inflicted illness) as rampant in today’s medical system. Similar protests are made by some feminists identified with the women’s health movement (Corea, 1977; Frankfort, 1972; Ehrenreich & English, 1973). Somewhat less severe criticisms come from patients, many concerned physicians, and the public at large, who are disturbed about the health negating consequences of overmedication, excessive surgery, excessive reliance on technology, overbureaucratization, and the shift of health care from the community to the medical center. Influential critics like Senator Edward Kennedy (1972) and other spokesmen for federal and state governments are concerned about the cost of care and the unavailability of care for many segments of our population, such as minority groups, the poor, and rural residents. It should be noted that these criticisms center around the practice of medicine—the application of scientific knowledge and techniques to patient care—and are not criticisms of scientific medical knowledge per se.

Family Medicine’s Position Within Medicine

In response to criticisms of medical care both within medicine and from society at large, family medicine has recently made extraordinary advances. The field was approved as a clinical specialty, residency programs for training new members were established, two national organizations representing family physicians’ interests were formed, and a refereed journal was begun. Even with these advances, many family physicians are still concerned with achieving a respected position within medicine. Some family physicians may merely want the additional prestige associated with other specialties, but the primary goal of others seems to be gaining the influence necessary to implement reforms within their own specialty and within medical education in general. The interrelationship between implementing reforms and establishing a more secure position within the field of medicine is a delicate question for family physicians (Carmichael, 1978) for reform has been the source of vitality for the family medicine movement, and this vitality could be lost in negotiations and compromises with established medicine (Stephens, 1976).

Indicators of an established position. In 1969 the Council on Medical Education of the American Medical Association (AMA) formally approved the specialty of family practice and recognized the American Board of Family Practice which is authorized to examine and certify physicians. The Board consisted of 15 members, five from the American Academy of General Practice, five from the Section on General Practice of the AMA, and one each from five specialty Boards—Surgery, Medicine, Pediatrics, Obstetrics-Gynecology, and Psychiatry-Neurology (Walsh, 1970). It is important to point out that the boards of the older specialties are composed entirely of members from their own specialty while the American Board of Family Practice includes one member from each of five other specialties. Family medicine draws from the clinical base of these five specialties in defining its scope of work. One can argue that representatives of these other specialties serve on the Board to assure clinical competence and expertise in their respective areas and to add prestige to board certification. Conversely, the presence of other specialists can be viewed by institutionalized medicine as a watchdog arrangement which reduces the professional autonomy of family physicians. One future indication that family medicine has proven itself to other specialties might be reconstitution of board membership to include only board certified family physicians.

The Board was charged to examine and certify three categories of candidates: (1) physicians who have completed a 3-year residency program in family practice, (2) those currently members of the American Academy of General Practice who held recertific...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Part I: OVERVIEW
• Part II: a. SOCIALIZATION
• Part II: b. PHYSICIAN/PATIENT ROLE