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Febrero 2018
Febrero 2018

History of Family Medicine Over the Past 50 Years. Global and European Perspectives

Verónica Casado Vicente

Especialista en Medicina Familiar y Comunitaria CS Universitario Parquesol. Valladolid

Verónica Casado Vicente

Especialista en Medicina Familiar y Comunitaria CS Universitario Parquesol. Valladolid

“No transformation in the field of medicine that we experience, have experienced or will experience in the future can occur away from historical knowledge; history has a fundamental role to play in any transformation.”

 

Javier Domínguez del Olmo1

Key points

  • The 19th century in America and Europe was the age of the general practitioner: a key professional for individuals, families and the community.
  • The first half of the 20th century saw the decline of general medicine in favour of medical specialities and its disappearance from universities.
  • Medical faculties discouraged interest in general medicine and the lack of postgraduate training led to an intellectually inferior image.
  • Family Medicine had three major influences: social, humanistic medicine; scientific, academic medicine, and the development of Primary Care.
  • The international medical community realised that newly graduated doctors were unprepared to deal with people’s problems.
  • General medicine colleges and academies dedicated to the academic development of the discipline were created in many countries.
  • Family Medicine has been spreading to all five continents since 1970.
  • The World Organisation of Family Doctors (WONCA) was founded in 1972.
  • The European Union of General Practitioners/Family Physicians (UEMO) has been defending the interests of GPs/FPs before the European Parliament since 1967 and participates in European Community directives on specific compulsory training.
  • The WHO (Alma-Ata, 1978) defines Primary Health Care as the preferred area of work of FPs in teams and for a specific community.
  • Changes in research and diffusion of scientific production were crucial in constructing the speciality.
  • 10 key “leaders” of Family Medicine today: Hippocrates, W. Osler, I. McWhinney, G. Engel, I. Heath, J. Tudor Hart, H. San Martín, A. L. Cochrane, H. T. Mahler and B. Starfield.

 

Introduction

When the journal’s editorial board asked me to write an article about the history of Family Medicine over the past 50 years, I thought it was a delightful yet undoubtedly complex task. This work is a subjective, non-systematic overview with a non-probabilistic, convenient selection of a bibliographic review that includes articles,2,3 books,4 doctoral theses5,6 and reports by the National Commission of the Specialty of Family and Community Medicine.

 

The most extraordinary thing about this history is that it is that of a worldwide project: the Family Medicine project.1

 

I would like to include three references before analysing these past 50 years: one as old as ancient Greece and the other two more recent, from the 19th century and first half of the 20th century.2-6

 

FIGURES 1 - 2
Hipocratés / William Osler

There were two medical schoolsin ancient Greece:4 the school of Kos and the school of Knidos. It was Hippocrates (Figure 1), creator and chief representative of the school of Kos, who said: “There are not diseases but rather patients” and it was the physician’s duty to “to cure occasionally, relieve often, console always”. The school of Knidos began a medical trend that paid maximum attention to the local disorder or illness and not to the general condition of patients, a concept that would be continued with Galen until the 20th century. The ideal of the school of Knidos was science and that of the school of Kos was science at the service of man. These two schools are clearly at the origin of the (prevailing) biological and biopsychosocial models.

 

The 19th century in America and Europe became the age of general medicine, which had gathered together virtually all the medical-scientific knowledge hitherto developed. In the 19th and early 20th centuries, the vast majority of the medical profession comprised general practitioners, those practicing medicine, surgery and obstetrics. Each family had its own doctor, usually for all family members, and this enabled continuity and a family approach. This general practitioner was an important figure for families and communities. He was a community leader, a counsellor, an epidemiologist, an advocate of social and even economic change, a permanent scholar and also a researcher. He resolved most of the problems he addressed with the technical and scientific limitations of the time. His role as a counsellor to the problems of his patients was recognised as a specific characteristic of these practitioners. In the period between the French and Industrial Revolutions, the term “family doctor” (médico de cabecera) appeared,7 referring to a practitioner providing care in the patient’s home by standing at the head (cabecera) of the patient’s bed. This term was thus associated with that of general practitioner.

 

First half of 20th century

The 20th century is considered the era of specialisation by scholars of the history of medicine.4,7 In 1910, Flexner8 presented a report that marked the beginning of the decline of general medicine in favour of medical specialities and its disappearance from universities. He had already warned that care should be taken because the overall view of the patient could be lost and that general practitioners such as Osler, Janeway, Haslted8-10 should not be ignored.

 

The early years of this century saw the emergence of what Ian McWhinney11 has dubbed the “major specialties”: internal medicine, surgery, paediatrics, obstetrics and psychiatry. Entry to these specialties was through postgraduate training and general practitioners were defined by their lack of additional training. It was assumed that any medical graduate could be a general practitioner and that general practice was not a clinical discipline in its own right. The technological explosion and scientific discoveries accelerated by two world wars encouraged this specialisation and super-specialisation, thus the number of specialists began to grow. In Europe during the 19th century, the ratio of general practitioners/specialists was 80/20, but this became 20/80 during the first half of the 20th century. Universities changed and their content was reorganised to include specialised and super-specialised material, and knowledge was divided into organs, apparatuses and systems. The absence of postgraduate training in general medicine or of chairs and departments contributed to creating an intellectually inferior image to that of their hospital colleagues.

 

Osler (Figure 2)9 had already warned that “the good physician treats the disease; the great physician treats the patient who has the disease”.7 As father of modern Hippocratic medicine, William Osler9,10 shifted the foundations of 19th-century medical education from classes to the bedhead of patients, bringing with him study and humanity in the doctor-patient relationship.

 

Three major influences on general medicine can already be identified during this time: social, humanistic medicine; scientific, academic medicine, and Primary Care as a field of action. And all three were influences in the creation of Family Medicine.

 

Social and academic orientation and the need for a structured, reliable field of action

Social medicine brought a holistic sense to medicine that was in line with the reforming discourse of general practitioners. The Dawson report12 defining health centres was published in Great Britain in 1920. It was not relevant at the time because of the medical response, but it greatly influenced the foundational reasoning behind Primary Care that WHO advocated in Alma-Ata and also social medicine. The model of neighbourhood health centres13 in the USA was also an influence, as was the Karkian model in Pholela (South Africa)14 in the 1940s, which led to Community Oriented Primary Care (COPC) in many countries, including Spain.

 

There was also a need for the academic consolidation of general medicine as a discipline and speciality. The first attempts of organising general practitioners to enhance the prestige of their practice emerged in the USA in the 1940s.15 The General Practice section of the American Medical Association (AMA) was set up in 1946, making it the first national professional organisation of general practitioners. Its members highlighted the need to emphasise a holistic approach to individuals and their families. The American Academy of General Practice was founded in 1947, the first scientific society of family physicians.

 

The organisation of general practitioners in Great Britain in 1948 was closely linked to the National Health Service, but the healthcare burden seriously threatened consultation times and care quality. To meet the demands of general practitioners, their practice deteriorated.16 J. S. Collings17 published a devastating description of British general medicine in The Lancet in 1950. He analysed rural, industrial and residential environments and described a notable difference in patterns. The British Medical Journal reacted vehemently, but nonetheless formed a committee to investigate general practice conditions. The article was truly shocking for British general practitioners (GPs) at the time.

 

Second half of 20th century

The proportion of doctors who chose general medicine, viewed by recent graduates as a more arduous, less prestigious job,18 was drastically reduced for reasons already outlined above and the allure towards specialities felt by young doctors.

 

But the scientific/technological advances were not without their side effects: loss of prestige, isolation of general practitioners and fragmented care; the approach was not to people, but to organs, apparatus and systems. This implied depersonalisation, increased system costs and the emergence of inefficiency pockets and care ceilings. The population itself began to question the fact that most of the problems were addressed by vertical medical specialists who were unfamiliar with the basic elements for a comprehensive approach to the health problems of individuals. The incredibly high costs of this health care and its relative effectiveness led to reflections by many professionals, planners and patient organisations in the USA, Canada, Great Britain, Nordic countries, etc. and this later extended to most other countries.

 

Beginning in 1950, the international medical community realised that faculty graduated doctors were not prepared to deal with the problems of the population. What was needed was a practitioner who could handle most of the needs of the population and attend to people in all their complexity. The practice of general medicine began to be viewed not only as the undifferentiated bulk of the profession, but also as a clinical discipline with its own body of knowledge. The speciality of Family Medicine appeared in the 1960s and spread to various countries in the 1970s.15

 

The efforts were focused on two areas: improving the profession and its working conditions and improving training in order to build a proper identity with a defined body of doctrine. General medical schools and academies devoted to the academic development of the discipline were created at this time in many countries and a dialogue was initiated between general practitioners and governments through their representatives.

 

United Kingdom

The milestone in the history of British general medicine was the Family Doctor Charter19 of 1966, around which revolved the desires of most general practitioners.

 

The Charter allowed for the ideological independence of a new college, the Royal College of General Practitioners (RCGP), which was founded in late 1952. It drew up its first document on postgraduate training in 1965, entitled “Special Vocational Training for General Practice”,20 which concluded that “if we want to keep a general practitioner service and attract young men into it, we have to make this career an equal challenge to a specialist career in hospital – and give equal rewards”. The report was decisive for the Royal Commission on Medical Education and it accepted general medicine as a speciality in the Todd Report (1968).21

 

The tension between undergraduate and postgraduate education impeded the former because of historical and political reasons. In 1953, the RCGP found that general medicine teaching was present in only three British faculties. The first chair of general medicine was set up in Edinburgh in 1963. There were eleven departments of general medicine with six chairs in 1972, while all medical schools had a general practice department in 1986. The introduction of general medicine in universities led to the recognition and strengthening of the specialty and this overturned the balance of student preferences, given that it has been a very popular choice from 1974 until today.

 

USA

In response to the same constraints – declining access to health care because of an insufficient number of doctors, tendency towards specialisation, insufficient generalist training and fragmentation of North American medicine – the US population and health care planners demanded the creation of a “physician who specialised in personal health care”.22,23 The Millis Commission Report of 1966, entitled “The Graduate Education of Physicians”,23 considered the immediate forerunner of specialised training, recommended specific postgraduate training for all Primary Care physicians, the creation of a theoretical body on holistic health care, an emphasis on out-of-hospital training, the establishment of certification mechanisms on an equal footing with other specialities and the strengthening of surgical training. General medicine or Family Medicine departments were set up in medical schools in the years that followed and training programmes were developed. Family medicine became a speciality certified by an ad hoc council. The American Board of Family Practice was organised as the official certification body for the new specialty in 1968 and it was formally established in 1969. In the same year, the first fifteen residency programmes were authorised in the USA and a model of postgraduate training was established. The first specialists graduated in 1971.

 

The creation of residency programmes went hand in hand with the creation of university chairs, given that the same university departments provided undergraduate and postgraduate training. In 1979, 103 of the 131 medical schools in the USA were teaching Family Medicine and were similarly organised to any other clinical specialty. In 1990, the American Medical Association (AMA) adopted the principle that all medical faculties in the USA must have a Family Medicine department.

 

Canada

In Canada, as in Great Britain, a belligerent minority of general practitioners took the initiative of founding the College of General Practice (later, Family Physicians) in 1954. It provided postgraduate training for general practitioners and taught general practice to medical students. The first certification exam by the College of Family Physicians was held in 1969.

 

FIGURES 3 - 4
Ian Mc Whinney / Halfdan T, Mahler

Its body of doctrine was defined over the years. In 1966, Ian McWhinney (Figure 3),11 originally from Britain, suggested creating a new language for the discipline and a unique body of knowledge with specific clinical skills that were capable of supporting research and possessing their own philosophy. He was appointed the first Professor of Family Medicine in Canada at the University of Western Ontario in 1967 and is thought to be the leading theorist in general practice. McWhinney claimed that Family Medicine was seen by some sectors as a subversive movement, but it was in fact a deeply conservative movement because it sought to restore values and ways of thinking that had always existed in medicine and had been forgotten in recent times.

 

Europe

In Europe, these principles have gradually been extended to all countries until today, with all medical schools now having a family medicine department: Belgium, Croatia, Denmark, Finland, Germany, Ireland, Malta, Netherlands, Norway, Poland, Portugal, Slovenia, Sweden and United Kingdom. Between 20 and 75% of faculties have a family medicine department in Austria, France, Greece and Hungary and 0% in Italy and Spain.

 

In terms of specialised training in Europe, it depends on universities in 36% and States in 64%. It is compulsory in all EU countries. It is considered a speciality in 93.3% of the countries belonging to the European Academy of Teachers in General Practice/Family Medicine (EURACT). Training periods range from 2 to 6 years, while 60% call it “Family Medicine” and 40% “General Medicine”.4

 

Latin America and the Caribbean

An awareness for implementing and developing Family Medicine programmes in medical universities began in Latin America and the Caribbean and postgraduate training in Family Medicine began in Argentina, Bolivia, Brazil, Colombia, Costa Rica, Ecuador, Mexico and Venezuela in the 1970s, extending to remaining countries in the 1980s. The Centro Internacional para la Medicina Familiar (International Centre for Family Medicine, CIMF) was established in Caracas in 1981. Its first managing director and founding member was Professor Julio Ceitlin (Argentina), alongside Pedro Iturbe (Venezuela). It was transformed into a federation of societies, colleges and associations of Latin America in 1994 and became dedicated to the development of Family Medicine in the American continent with the help of Javier Domínguez del Olmo (Mexico), later becoming the VI Region of WONCA in 2004.1

 

Asia and Pacific

Family Medicine training is also present in many Asian and Pacific countries. It is a recognised specialty in Australia, Hong Kong, Malaysia, Philippines, Singapore, South Korea, Taiwan and New Zealand and is also present in China, Egypt, India, Israel, Japan, Nigeria, Russia, South Africa, Ukraine and Vietnam. An Arab committee oversees specialised training in Jordan, Kuwait, Oman and Saudi Arabia.24

 

WONCA and UEMO

The many initiatives to create Family Medicine in a great majority of countries led to the organisation of world conferences of family/general practitioners and WONCA (World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians), abbreviated to World Organisation of Family Doctors, was officially established in 1972 at the Fourth World Conference of General Practice in Chicago, in 1970. It interacts with WHO, with which it maintains official relations as a non-governmental organisation, and plays an academic and content role. It currently comprises seven regions, and Spain belongs to two of them through semFYC: WONCA Europe and CIMF/WONCA Iberoamericana.

 

In Europe, there is also the Union of General Practitioners/Family Physicians(UEMO), which is linked to the European Union of Medical Specialists (UEMS) and plays a more political role, defending the interests of general practitioners/family doctors before the European Parliament since 1967. In 1977, the Committee of Ministers of the Council of Europe issued a resolution establishing that Family Medicine should be the cornerstone of health systems. This organisation was crucial to the legislative progress of specific training in Europe. It participated in the drafting of the European Community directive on specific obligatory training in general medical practice, for a period of at least 2 years, in order to exercise the profession in all Member States (Council Directive 86/457/EEC of 15 September 1986). UEMO has had official, non-governmental consultative status with the Council of Europe since 1992.

 

Discursive elements

Family Medicine is thus defined as an academic discipline and as a medical speciality, because it has a preferential area of action, Primary Care, with its own body of knowledge (high prevalence and incidence medicine, clinical preventive medicine and Family and Community Medicine), with a specific action paradigm and orientation: the biopsychosocial approach, longitudinality and comprehensiveness, with an ancient historical tradition and several international researchers. New training programmes are based on two important educational principles. First, just as in other clinical disciplines, trainees must learn basic skills, core learning, through supervised practice in their own discipline: the Family Medicine teaching unit. Second, supervisors and teachers must be family doctors. Other clinical specialists and educational settings play a role in the curriculum, but it is not central. Family Medicine departments occupy an important part of undergraduate curricula at universities in many parts of the world,.

 

The Alma-Ata Conference in 1978 defined Primary Care and it has now become the preferred working environment for family doctors as a team and for a defined community. Halfdan T. Mahler (Figure 4), WHO’s third director from 1973 to 1988, will be remembered as a tireless advocate for Primary Care. He displayed crucial leadership in shaping the Alma-Ata Declaration of 1978,25 which defined the Global Strategy for Health for All by the Year 2000 and was endorsed by 134 countries.

 

Name change

These developments in some countries were accompanied by a change of name from general medicine to Family Medicine, while in others the old name was retained for a new discipline. The specialisation process in North America only succeeded when new professionals gave up the name of general practitioners, which was considered archaic and unscientific. McWhinney11 pointed out that the American founders of the Board of Family Medicine had repudiated the name of general practitioner. Documents by WHO experts and the Willard Commission proposed “family practice” or “family physician”.18,23 The National Commission on Community Health opted for “personal physician”, while the Millis Commission defended that of “primary physician”.22 The one considered most descriptive and dignified was ultimately that of “family physician”. In Great Britain the term began to be used in 1911, but never reached the strength it achieved in the USA, due to the prestige already obtained by general practitioners (GPs) in that country. The reasons for this name change, when looked at closely, have more to do with those who defend this discipline and speciality. When it is done by general practitioners, the name is retained and strengthened, as occurred in the UK, while in other countries its defence comes from planners or society itself, as occurred in the USA, so they had to create a new professional model and Family Medicine was thus born.

 

Interest in the person and in social and epidemiological aspects

FIGURES 5 - 6
George Engel / Ioana Heat

Based on the general theory of systems, George Engel (Figure 5)26 in 1977 once again claimed that the social context in which people live and their psychological and biological characteristics interact in each individual.

 

The biopsychosocial model presented a new resurgence with the general scientific paradigm shift, which began in the 20th century with the general theory of relativity and uncertainty principle of quantum physics. The foundations of the model in this new way of understanding the reality of human beings do not contradict but rather complete biomedicine, in the same way that has occurred in the remainder of the sciences. Thus, one returns to the paradigm of the school of Kos: science at the service of people. The discursive elements of our speciality have been humanism, comprehensive care, doctor-patient relationship, interest in family and community care as an element of social legitimacy, preventive medicine, organisational structure and work patterns, academic aspects as a discipline and specialty. The value achieved by preventive medicine in the new general medicine was strongly backed by international agencies.

 

Iona Heath (Figure 6) is an outstanding figure among the people recognised for their defence of humanism, ethics, social equity and justice from the field of Family Medicine and those who have probably had the greatest moral influence on family physicians. Heath is a British general physician practicing in one of London’s poorest suburbs, a regular contributor to the BMJ, whose ethics committee she chairs, and a former president of the Royal College of General Practitioners (2009-2012), as well as heading the Health Inequalities Task Group from 1973 to 2003. Not only does she have a good knowledge of the professional practice of a family doctor, she also has a great ability to analyse the main issues of our time, from the medicalization of society to human genetics, old age or reflections on death. Her book Matters of Life and Death. Key Writings 27 should be a must-read in universities and teaching units.

 

Michael Balint, the psychoanalyst son of a GP, worked extensively on the doctor-patient relationship with a relatively small group of general practitioners, all leaders of the RCGP and Family Medicine university departments. He had a profound influence on the profession, highlighting the benefits of continuity, communication and doctor-patient relationship.

 

FIGURES 7 - 8
Julian Tudor Hart / Hernan San Martin

The interest in community also shaped and legitimised the Family Medicine discourse and gave it its second name. Community care added a more social nuance to Family Medicine. Julian Tudor Hart (Figure 7) was born in London in 1927 and collaborated with Archie Cochrane and Richard Doll. He is the author of the inverse care law,28 which states that “the availability of good medical care tends to vary inversely with the need for it in the population served”. He created a classic aphorism in European Primary Care – “There is intelligent life outside the hospitals” – and was a very influential family doctor in the early generations of Spanish family doctors. He conveyed pride in being a community doctor and helped to construct the identity of Spanish family doctors on the basis of humanistic and clinical quality. His influence undermines the thesis that attributes the not always well-intentioned community orientation of Spanish Family Medicine to an exclusively Latin American and especially Cuban origin. This influence indeed also existed, since many early generation family doctors were trained in community health in Latin America, where their development has always been very important. The influence of teachers such as Hernán San Martín (Figure 8) and Ernestina Presser is significant. Hernán San Martín was born in Curicó (Chile) on 23 September 1915. Many of his books were published in France, where he was a refugee. Particularly noteworthy among these is Salud y enfermedad, originally published in Cuba in 1962 and later becoming a classic of Latin American public health. Another key physician in the field of public health and epidemiology is Archie Leman Cochrane (Figure 9), whose most important work is undoubtedly Effectiveness and Efficiency,29 which he published in 1972. He had, and still has, a decisive influence on all universal medicine, not only Primary Care.

 

FIGURES 9 - 10
Archiel Leman Cochrane / Barbara Starfield

Family Medicine and Primary Care as research subject and field

Many researchers focus on Primary Care and Family Medicine as the subject of their research and their work has shed light on the impact that these have on the health levels of populations. Farmer and his collaborators were the first to show in 1991 that those with the lowest age-adjusted mortality rates had the highest density of family doctors based on data from all US counties. The Primary Care variable most related to differences in health indicators is the number of family doctors in Primary Care.30 They reported that the increase in the number of family doctors in Primary Care per 10,000 in the population reduces all-cause mortality, cancer-specific mortality, cardiovascular and cerebrovascular diseases, infant mortality, low birth weight and self-perceived ill health.31 Macinko and his colleagues even associated this increase in the number of family doctors with an average reduction in mortality of 5.3%, or 49 per 100,000 inhabitants per year.32

 

Barbara Starfield (Figure 10) is one of the most uniquely outstanding figures among all Primary Care researchers. She has been a true revolutionary and her work entitled “Is Primary Care Essential?”,33 published in The Lancet in 1994, began to demonstrate with data the power of Primary Care and converted it into something evident rather than a philosophy and utopia.

 

Research developments have been extremely important in constructing the speciality and destroying the anti-intellectuality that, according to some, defined general medicine. The dissemination of scientific production through publications and books forms part of the development of the speciality (Table 1).

 

 

TABLE 1

 

Historical references of publications and books

1950

First scientific magazine for general practitioners: General Practitioner

1951

“General Practice” defined as a research subject

1955

Research Newsletter

1958

Research Newsletterbecomes the Journal of the College of General Practitioners

1966-1968

 Books begin to be written by family doctors

1968

The subject dubbed “General Practice” is subdivided into “General Practice” and “Comprehensive Health Care”

1972

First meeting of the North American Primary Care Research Group: first research forum into Family Medicine

1973

 First major treatise on Family Medicine: Conn HF, Rakel RE, Johnson TW (eds). Family Practice. Philadelphia: Saunders, 1973

1974

Journal of Family Practice: first journal of Family Medicine peer-reviewed by family doctors

1978

“Family Practice” replaces “General Practice” as subject matter

Summary

The conceptual and philosophical development of Family Medicine derives directly from the school of Kos (Hippocrates). The 19th century was an age of general medicine, while the end of that century and the first half of the 20th century were an age of specialisation. Its appearance generated insight, but also fragmented knowledge, essentially in systems, apparatuses and organs. This meant the disappearance of general medicine from universities alongside that of its holistic view of individuals and their families. The academic discipline and speciality of Family Medicine originated in the second half of the 20th century. After the gradual disappearance of general practitioners and vertical specialisation, not only did costs begin to rise, but society also demanded that people should be comprehensively cared for by qualified, competent doctors who need to depend on their own well-defined body of doctrine and also improved working conditions.

 

Recommended reading

Fajardo Alcántara A. El proceso de especialización en Medicina Familiar y Comunitaria en España. Cambios profesionales en Atención Primaria en la década de 1980.Doctoral thesis. Granada: University of Granada, 2007. [Quoted 29 October 2017] Available at: https://saludcomunitaria.files.wordpress.com/2010/08/16925506.pdf

Amigo Rodríguez P. Institucionalización de la Medicina Familiar y Comunitaria como especialidad médica en España (1978-2008). Doctoral thesis. Salamanca. Ediciones de la Universidad de Salamanca; 2011. [Quoted 29 October 2017]. Available at: https://gredos.usal.es/jspui/bitstream/10366/76389/1/DPPMMLHM_Amigo_Rodriguez_P_Institucionalizacion_de_la_medicina.pdf

I recommend these two doctoral theses to all people, whether family doctors or not, who are interested in the history of Family and Community Medicine, as they constitute a rigorous study of the beginnings and development of Family and Community Medicine, the former in the 1980s and the latter from the creation of the specialty until 2008. Both of them are truly magnificent.

 

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AMF 2018; 14(2); 1; ISSN (Papel): 1699-9029 I ISSN (Internet): 1885-2521

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