Monthly Archives: February 2013

The Paradox of Generalist Specialists

General practitioners of medicine (GPs), the medical heroes of World War II, returned home only to find their medical standing at their local hospitals in jeopardy.  Specialization made great inroads during the war years, and, while the GPs were fighting the war in Europe, many hospitals reclassified their staff physicians on the basis of specialist qualifications.  GPs of course were low men on the totem pole, and some found that the very hospitals where they had worked before the war had rescinded their surgical privileges after the war.  Stanley R. Truman, the first Secretary of the American Academy of General Practice and chronicler of its founding, recalled this very situation at his own Merritt Hospital in Oakland, CA.  “Some of these men had gone away with major surgical privileges,” he later recalled, “and had been assigned leading surgical responsibilities here and overseas.  They were furious when they came home and found themselves in ‘Class A’ [the lowest rung of the hospital hierarchy, in which surgery could only be performed after consultation and under supervision].”  One day in late 1945, Truman continued,

I met Harold Maloney who had just come back.  He was one of our leading general practitioners; a fine doctor and surgeon; a member of the American College of Surgeons and in ‘Class A.’ We had previously talked about an organization of general practitioners; and this day, in talking the situation over again, we agreed that an organization was urgent.[1]

And so the GPs organized, first into the General Practitioners Association of Truman’s Alameda County; then in 1945 into the Section on General Practice of the American Medical Association; and finally in 1947 into the American Academy of General Practice (AAGP).  The organizers and officers of the AAGP, who assumed the burden of promoting the new organization and encouraging the formation of local chapters, made no bones about the reason for its existence .  It was not about “family practice,” “comprehensive care,” “total patient care,” or any of the other buzzwords that were invoked in the discussions two decades later that led to the creation of the American Board of Family Practice in 1969.  It was about power pure and simple, and power in postwar America meant the power to treat one’s patients in the hospital, including patients who required operative obstetrics and major surgery.

Returning GPs, who, as General Medical Officers, had met wartime needs at both ends of the specialty spectrum – in psychiatry and in surgery – were aghast at rumors that certain stateside hospitals – perhaps their own hospitals – planned to limit their staffs to board-certified medical specialists by the early 50s. Was this their reward for exemplary service to the nation?  “Since the second World War,” intoned the AAGP’s first President, Paul Davis, in 1948, the GP “has been discriminated against in many cases, and had his professional standards encroached upon.”  In 1953, two of New York’s leading GPs recollected:  “It was as if the hospitals were about to put up signs reading: ‘If you’re a general practitioner, keep out!”  A few years later, Eric Royston, another prominent AAGP booster, recalled the postwar feeling among GPs of being discriminated against in their medical associations “and being pushed to the periphery in the metropolitan hospitals.”[2] The AAGP would come to the rescue; it would have the strength of numbers,[3] which meant it would have the power. The AAGP’s resolve to keep GPs in the hospitals and put scalpels back in their hands was baldly stated in Article II of the its constitution, which set forth this organizational objective:  “To preserve the right of the general practitioner to engage in medical and surgical procedures for which he is qualified by training and experience.”[4]

But all did not go as planned.  Although the AAGP stabilized the GP’s hospital status as it existed before the war, it could not protect GPs from the continuing development of specialty medicine, which increasingly took place in hospitals and entailed ever more sophisticated procedures and interventions.  Specialty encroachment of GP hospital privileges might be slowed but never halted.  And along with the organizational support came the stigma, which is exactly what the AAGP sought to prevent.  In the late 40s, many GP-surgeons resisted joining the AAGP lest — publicly identified as GPs – they have their surgical privileges rescinded.  On the other hand, the few GP residency programs that proved successful in the early 60s, mostly in California, were those that taught surgery and permitted GP residents to perform major operations.[5]  It was all about surgery, all about procedures, all about treatment-related prerogatives within the hospital.

Of course, the AAGP could not prevail, given the great impetus to specialization provided by the war.  When, in the mid-1960s, efforts to upgrade the status of the generalist centered around creation of a new residency-based specialty, “family practice,” it was no longer a matter of surgical privileges within the hospital.  No, family practice would be a new and different kind of specialty, one less concerned with procedures and surgeries than with holistic, patient-centered, intergenerational caregiving.  The retreat from proceduralism was codified in the “Core Content” of family practice adopted by the AAGP in 1966.  The family practitioner (FP) of the future, it held, would assume “comprehensive and continuing responsibility” for his or her patients.  This meant that family practice would be a  “horizontal specialty” that cut across the other specialties.  It would fall back on “function” rather than a “body of knowledge.”[6]

What was lost in the new rhetoric of patient-centered caregiving was the very thing that mattered so much to the AAGP two decades earlier:  safeguarding the GP’s prerogative to perform those procedures and interventions that fell within the domain of the practicing (as opposed to the caring) generalist.  The proponents of family practice could no longer hope to wrest control of a piece of the medical pie, so they elaborated a new – and, they fervently hoped, specialized – gloss on the pie in its entirety.  This amounted to proposing a “sort of a focus”[7] for the residency-trained FP of the future.  What FP proponents and educators failed to do was delineate in a conventional manner the procedural correlates of the FP’s “focus” – the things that all FPs would be trained to do that qualified as specialist interventions, not just attitudinal correlates of caregiving that meshed with their person-centered ideology.

The question-begging nature of early definitions of family practice is nowhere more evident than in the matter of surgery.  By the mid-60s, the founders of family practice realized full well that the American College of Surgeons would never cede residency-trained family practitioners the prerogative to perform major operations in the hospital. Furthermore, adding insult to injury, the AAGP was beset with a schism within its own ranks:  there were GPs who did considerable surgery (including operative obstetrics) and GPs who did not.  The former believed family practice should include a strong surgical component; the latter did not.  The former were concerned about the exclusion of surgery from “modern” family practice, and for this reason they opposed the development of a family practice specialty board through the early 60s.  The pragmatic (non)solution to this quandary was simply to leave the issue open.  The AAGP’s vision of the new family practice specialist, as spelled out in its “Core Content” position paper of 1966, assigned family practitioners the nebulous domain of “applicable surgery,” meaning that “the physician in family practice should be trained to do the types and kinds of surgery he would be required to perform after graduation.”

There is irony in this nebulous manifesto:  the very effort to transform old-style general practice into specialized family practice hinged on a willingness to fall back on a pre-1930s notion of specialization in which generalists would somehow know, in advance of practice, what kinds of techniques they would need to master for their future work.  They would then “pick up” these techniques during residency or after residency in the world of everyday practice and occasional postgraduate courses.  Family practice, in these mid-60s deliberations, increasingly looked like a specialty that was not only “different,” but antithetical to the very meaning of specialization.  That is, if family practice is a medical specialty of any kind, then all FP residents should receive common training in a range of diagnostic and treatment procedures that, in their totality, add up to specialist interventional care.  The willingness to localize procedural skills, to leave it to individual practitioners and/or training programs to determine which skills would be “appropriate” to practice, was a nod to the surgical specialists, whose advanced training and control of hospitals was shored up by the postwar climate of opinion.  But it had the paradoxical effect of marginalizing the family practitioner out of the gate:  once you begin localizing the procedural, hands-on component of any specialty, medical or otherwise, you risk gutting the specialty, cutting away the shared procedural content that coalesces into expert knowledge and sustains a common professional identity.  What kind of specialty leaves it to the individual to fill in the procedural content of the specialty as he or she proceeds through training and practice?

Here we have a central dilemma of family medicine.  I invoke it here in support of the need for a new kind of generalist physician who is procedurally empowered in the manner of GPs of the 1940s and 50s.  We need to oscillate back to generalists who can do many things and away from generalist physicians who hypothetically know their patients “better” but are increasingly content to “coordinate” their care.  The family practice movement failed because it sought the impossible: to create a new kind of specialty that would not delimit expertise in treatment-specific ways.

The family practitioner of the 1970s was to be an interpersonally embedded, empathically attuned, total-patient provider.  He or she was to provide comprehensive care that was intergenerational, mind-body care.  Proponents of the movement spent years debating what “comprehensive care” meant, and ultimately had to beg the question.  The result was a medical specialty that, until recently, lacked consensually agreed on procedural requirements.  The semantically strained, even oxymoronic, vision of a non-specialty specialty, a specialty that rejected specialist values, was an amalgam of 1960s counterculture, the social sciences, and a dash of psychoanalytic object relations theory (per Michael Balint), all abetted by the dearth of “personal physicians” and the emergence in the 1970s of the patient rights movement.   Family practice was of its time – it was entirely admirable and terribly ill-fated.  This is why only eight percent of non-osteopathic medical students now choose to “specialize” in it.[8] It is also why some top-tier medical schools — Harvard,  Yale, Johns Hopkins, Columbia, and Cornell, among them —  do not even have departments of family medicine.

If we are to address the primary care crisis within rural America, we need a new kind of doctor – call them specialists in procedural rural medicine (PRM) or rural care proceduralists (RCPs) – who can actually take care of people in rural settings where specialists are sparse.  Such physicians will not do many things, certainly not the kinds of surgeries that GP-surgeons of the postwar era felt within their province. But they will be trained to do much more than the majority of contemporary family physicians.  Their connection with their patients will rely less on prescribing and coordinating than on what W. R. Houston, in his justly celebrated address to the American College of Physicians of 1937, termed “the line of procedure.”[9]  We need primary care physicians who do things to their patients’ bodies.  Such physicians will “touch” their patients in the dual sense of activating an inborn biological pleasure (contact touch) and allowing such pleasure, through symbolic elaboration, to become a touchstone of a trusting doctor-patient relationship.[10]  A renewal of procedural medicine will not make indifferent caregivers caring, but it will fortify in the realm of action what Houston termed the “dynamic power” of the doctor-patient relationship.  It will make it easier for caring doctors to doctor.

In the next essay in this series, we will look further at procedural rural medicine and how it would differ from family medicine as it currently exists.

[1] S. A. Truman, The History of the Founding of the American Academy of General Practice (St. Louis: Green, 1969), p. 16.

[2] P. A. Davis, “The American Academy of General Practice,” Southern Med. J., 41:651-55, 1948, at p. 654; W. C. Allen & S. A. Garlan, “Educational motivation in the field of general practice,” NY State J. Med., 53:1243-1245, 1953, at p. 1243; E. A. Royston, “The American Academy of General Practice:  its origin, objectives, growth and outlook,” S. Afr. Med., J., 30:298-99, 1956.

[3] The AAGP had well over 2,000 members by the end of 1947, the year of its founding.  By 1968, membership had grown to 30,000.  Truman, op cit., pp. 54, 60.

[4] N.A., Family Practice: Creation of a Specialty (American Academy of Family Physicians, 1980), p. 34; Truman, op cit., p. 43.

[5] Family Practice: Creation of a Specialty, op. cit., pp. 12, 20.

[6] Family Practice: Creation of a Specialty, op. cit., pp. 37-38.

[7] Family Practice: Creation of a Specialty, op. cit., p. 42.

[8] W. S. Biggs, et al., “Entry of US medical school graduates into family medicine residencies: 2011-2012,” Fam. Med., 44:620-626, 2012.

[9] W. R. Houston, “The doctor himself as a therapeutic agent,” Ann. Int. Med., 11:1416-1425, 1938.

[10] See, for example, N. S. Lehrman, “Pleasure heals: the role of social pleasure—love in its broadest sense—in medical practice,” Arch . Intern. Med., 1993;153:929–934.  Contemporary physicians writing about primary care have little to say about the salience of the laying on of hands – even when mediated by instrumentation – as a component of care-giving that mobilizes patient trust.  But there is much to be gleaned from contiguous literature, e.g., G. Pohl, et al., “’Laying on of hands’ improves well-being in patients with advanced cancer,” Support Care Cancer, 15:143-151, 2007; S. Jain, et al., “Healing touch with guided imagery for PTSD in returning active duty military: a randomized controlled trial,” Mil. Med., 177:1015-1021, 2012;  and T. Jones & L. Glover, “Exploring the psychological processes underlying touch: lessons from the Alexander technique,” Clin. Psychol. Psychother., Nov., 2012 (Epub ahead of print).

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.