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The Family Physician, the Heart of Medicine
Presented before the Fifty-Second Annual Meeting of the American Therapeutic Society, Atlantic City, June 8-10, 1951. Published in Annals of Western Medicine and Surgery, Vol. 6, No. 10, June 1951, pp. 714-715.
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The family physician is the hero of medicine. To be sure, in recent years his heroism has been unsung. This has been a time of confusion when he was all but submerged in the stream of economic and social change on the one hand, and rapid advances in medical knowledge on the other. He cannot be displaced. Fortunately he has not been overcome. He still is the heart of medicine, but a heart which needs strengthening.
During the past half century, through the rapid development of science, new facts in medicine have been discovered so rapidly that it has been almost more than one mind could do to keep abreast of the advances in one anatomic system or one disease. So, for the time, specialization has taken the center of the stage. To make this period more difficult it has not only been a time when knowledge was being developed but also one in which accepted facts were being questioned and often discarded.
It has been truly a trying period for both patient and physician. The patient has often attempted to divide himself into his component parts and without medical direction to seek out the specialist who seemed to him to be the one trained to care for his special illness. It is no wonder that the heart patient has sought a chest specialist; a tuberculous patient a throat specialist; sufferers from many diseases have taken their gastrointestinal symptoms as indicating disease centered in that particular system; and the nervous and psychic patients have sought first one and then another specialist until they have made the rounds of all, often to find because no organic disease was discovered that none was interested in their bothersome complaints.
One lesson is derived from all this, namely: the human body is a unit and he who approaches it as such is the master craftsman. That man is the general practitioner who sees sickness as it comes to the people without being classified. But how can he know the human body as a whole, and the varied manifestations of all the different maladies, when men in specialties have found it necessary to devote all their study to one limited subject? Surely he could not, during the rapid development of the specialties in the past half century. But now the time is approaching, if not already here, when he can; or, if not, he can at least know where the available knowledge can be had. We must train family physicians who can perform the role that the name implies. That is a necessary function of medical education.
Function is to Clarify the Whole of Medicine
Specialties are now well developed and each one of them possesses a volume of basic facts which are definite. These facts are fast becoming the property of medicine to be mastered and utilized by all students of the healing art. The greatest contribution that the specialist can make is not the care and expert treatment of a given patient or one suffering from a given disease or system, as it has been in the past quarter century, but to give to medicine as a whole a clear picture of the facts which have been established by his study and skill. His function is much the same as that of the laboratory—to improve the whole of medicine. I can see him in a consultant capacity by whose advice the general practitioner is able to give his patient the benefit of the best that has been developed. Aside from the specialist’s addition to the entire subject of medicine, he could well become the member of a group in which family physicians and specialists unite. This might be centered in a hospital or in a clinic with hospital connection. If this is not feasible, then some other method must be devised in which consultation can be freely used.
Social Force of Medicine to Advance
When will this change in the form of medical practice take place? No one can answer. But the change is already in the making. Who, in 1900, would have thought that by the midcentury 50 percent of the graduates in medicine would be practising a specialty in whole or in part? And who would have thought that the most scientific medicine that has ever been developed would not reach and satisfy the people? But this we are now forced to realize. There is a wide and unfilled gap between the patient and the specialist which can be filled only by the family physician who sees all patients and knows the fundamentals of all the usual diseases. Much of this illness consists of minor complaints, but it must be cared for.
In quality, treatment by specialists may be scientific but it is often too impersonal. Too much attention is given to the diseases and the mechanical methods of examination; too little to the psychical and emotional side of the patient; and this, to the patient, in comparison with the family physician of yore, amounts to disinterest and neglect. A patient with an illness is sick both physically and emotionally and needs someone to show a friendly interest in him. It was the recognition of this latter fact which made the old family physician so appreciated and loved by his patients, even though he knew little of medicine as we know it today. We must restore this confidence in medicine probably not to the same degree as in the prescientific days but to a far greater degree than we now have it.
One of the greatest dangers to medicine today is its failure to take into account the changes which have taken place in the economic and social structures during recent years. We have made more advances technologically in the past seven or eight decades than in the previous ten centuries. In medicine we have made similar strides scientifically. But socially, as a nation, we are not far above our status in the eighteen eighties, and in medicine we have almost destroyed that great social force of service which has dominated medicine since the time of Hippocrates.
Two Worlds Contrasted
Fundamental to understanding what has happened to the patient-physician relationship today it is necessary to know that the world of the twentieth century is wholly different from that of the nineteenth. Compared with his parents when they were ill, the sick individual finds himself totally uprooted economically and socially and he has many more medical problems than his parents had and of a different nature. However, these problems are of a character which requires the same sympathetic approach as given by the old family physician in his parents’ time.
Is Medicine a Monetary Transaction?
The amount of medical care is often much less than is desired partly because of cost and partly because of the lack of the traditional spirit of personal interest, such as was shown by the old family physician. The cost of medical education has multiplied several times; the cost of remedies has skyrocketed; and hospitalization is too expensive for many. Furthermore, according to present practice more diseases require hospitalization both for diagnosis and treatment than ever before.
Most hospitals, except municipal and state institutions, have been built by churches or other organizations, or by private contributions. So a considerable proportion of patients are not paying the full cost of hospital care, and yet the cost is beyond the financial ability of many who do not desire charity.
When services are beyond the ability of the patient to pay for, or when resented because there is shown a lack of personal interest in the patient, a situation is created which medicine cannot allow to go unchallenged. Regardless of the extra demands of education and equipment, we cannot allow the practice of medicine to assume too much the form of a monetary transaction.
Partly because of these factors the physician is held responsible for delivering a thoroughly satisfactory and exact product. The patient refuses to pay for something that he thinks he does not get. This is one reason why many suits for malpractice which are unjust are brought against medical men. Hospitals for their own protection choose their staffs with great care. To a large extent they have closed staffs consisting mostly of high ranking specialists. Only those of comfortable incomes can freely avail themselves of such services; yet illness afflicts all and the lower income groups most.
What is the family physician, who should be the first to see patients, to do with those who need hospitalization if he has no hospital connection? Is he to treat them as best he can in the home, refer them to some other physician who is a member of a hospital staff; or must he send them to a charity hospital? None of these alternatives is satisfactory. Hospitalization must be available for all who need it, and the profession as a whole must be trained and qualified, and have the opportunity to give it when required. Insurance is an important factor, but it must be developed to the point where its application is general and comprehensive. It must be applicable to patients of the family physician as well as those of the specialist.
Standards of Practice Improved and Available Tools Provided
What is the answer? First, we must elevate the standard of the general practitioner. He must be given the training which will prepare him for filling the most important role in medical practice; and we must give him the tools with which to work. He must have special hospital training and laboratories and consultants, and hospitals to which he can send his patients, so that he can practice the medicine which he is taught. His patients will not be a chosen group but will consist of the mass of Americans who make up our communities and determine our national status. They cannot all afford the high prices that present practice requires, but all deserve the best for all are important to our national well being.
This will require changes in our medical curricula, and in our general medical practice. Our hospitals will be obliged to have special courses which will afford the opportunity which such training demands. This, too, will require more time for preparation and be more costly, so paid residencies will probably be required, or some preceptorial system will necessarily be provided to teach the art of medicine. But how will this give the answer? By restoring the heart of medicine to its normal function. Then will the family physician become the major force in medicine, and service will once more become an important phase of medical practice.
If the family physician is enabled to give adequate care to his own patients, and through group practice or some other method to secure consultants for those who need special attention, he will be able to reduce costs and give to the ill the benefit of the best in medicine along with the service for which the family physician has always been known. He will cultivate a closer personal relationship with the patient, and thus regain the confidence and esteem of the public which is most sadly lacking today.