[Below, from left: Charles E. Odegaard, Ph.D., President Emeritus, The University of Washington, G. Gayle Stephens, MD, and William H. Burnett, MA of the Coastal Research Group.]
Presenting the Second G. Gayle Stephens Lecture at the Third National Conference on Primary Health Care Access in Colonial Williamsburg, Virginia
John Arradondo, MD, MPH, Houston, Texas It is my pleasure to introduce our second G. Gayle Stephens lecturer. It was very appropriate that at the Second National Conference on Primary Health Care Access, we inaugurated a lecture series to honor Gayle Stephens, whom, as all of you know, is both a pioneer and continuing revolutionary in family medicine. Any kind of movement would needs both pioneers and revolutionaries. They are not always the same.
Gayle, when appropriate, can be iconoclastic; when appropriate can be pushy; when appropriate can pull people; when appropriate can follow. He happens to have a view that is long and broad enough to be able to serve as a senior statesman when necessary, and that is very important both for primary care and for family medicine in particular. Most of you heard the inaugural lecture which Gayle himself presented. It is very appropriate that he should have inaugurated this series with a nice allegory, which I entitle “the Case of the Red Bull”.
Today, we are honored to have someone who can clearly follow in this series of lectureships – someone, who, interestingly, was a historian before he became associated with the medical field. Only recently did I discover that he was a specialist in medieval history. The moment I discovered that, I understood intuitively his appropriateness for the medical – health industry, and, after discussing this background with him, I understood it even intellectually.
Because of that background and his interest, he served on the Millis Commission, which came out with the term “primary care”. He served on some of the other health care commissions of the 1960s, that led to the concepts of primary care and from which family practice acquired its new name, replacing general practice. Many of the current ideas that have helped define primary care have their roots in these commissions and influenced the fields of internal medicine and pediatrics, and, occasionally other medical specialties as well. The ideas also influenced the course of the nurse practitioner, physician assistant, and nurse midwife movements.
Doctor Odegaard was drawn into the world of medicine by becoming the President of the University of Washington, and served a distinguished period of time in the history of one of our country’s great universities. Near the end of his university presidency and after leaving it, he has participated in other valuable policy studies. He reviewed the original 11 Area Health Education Centers. He also did a report on minorities in medicine. Beyond that, he has and does serve as a member of the Institute of Medicine. From my perspective, I consider him a friend of primary care. Please welcome to this podium, Doctor Charles Odegaard, the President Emeritus of the University of Washington, our second G. Gayle Stephens lecturer.
Charles E. Odegaard, Ph.D., University of Washington Well, ladies and gentlemen, it is a great pleasure for me to stand here before you in the role of a follower of Gayle Stephens. At the Second National Conference, held a year ago, that veteran family physician provider of primary care himself presented a hard-hitting argument as to the need for more physicians interested in, and capable of, providing a much more comprehensive kind of program for the training of doctors. He described primary care in medical practice as low-tech medicine, in contrast to high-tech medicine, which addresses almost exclusively biological perturbations in the body of the patient and which we know is the particular domain of the many kinds of medical specialists who dominate the medical schools today.
Dr. Stephens affirmed: “There is a mismatch — a gap between epidemiological knowledge and the knowledge of persons. There is a mismatch between the demography of doctors and patients. We have a young, white, rich medical profession and a population that is aging, increasingly diverse ethnically, and by most estimates, contains 35 to 40 million people who are poor enough to be uninsured. This demographic mismatch promises that more doctor-patient encounters in the future will be ‘cross-cultural’ and that age, race, and social class will be dealt with if medicine is to be personal rather than merely technological”.
I begin this lecture by expressing agreement with the main tenets in Doctor Stephens’ address, which he named “The Best Ideal of Family Practice”. They concur with the recommendations of a report in 1966 in which I participated, entitled “The Graduate Education of Physicians”. The report of the Citizens Commission on Graduate Medical Education was commissioned by the American Medical Association. This report has often been referred to as the “Millis Commission” out of respect for its chairman, John Millis, then President of Case Western Reserve University.
The Millis Commission, appointed by the AMA leadership, was unusual in its membership. It consisted of a minority of three specialty physicians and a majority of non-physicians as follows: the director of labora-tories of a pharmaceutical company, the president of a large business corporation, a retired justice of the United States Supreme Court, a psychologist executive officer of the AAA, a sociologist professor, a lawyer president of a university, a historian university president, and as chairman, a physicist university president.
A brief explanation of this unusual membership is in order. By the 1960s, the AMA had a troubled membership. It was a house divided. All physicians educated for the profession of medicine in the United States from the beginning of the century have been exposed in American medical schools to a heavily oriented biomedical curriculum to what the GPEP Report refers to as the Flexnerian model. By the 1960s, there was a significant variation in the age groups of physicians in the United States. Most of the older physicians had completed their formal professional preparation for the practice of medicine in the earlier four decades of the century largely within the four year biomedically oriented MD program and had entered the practice of medicine without much subsequent intensive specialist orientation.
In contrast to this older group, a higher and higher proportion of recipients of the MD degree after World War II had continued their education beyond the MD level to achieve advanced certification in the heavily biomedical specialties. Thus, by the 1960s, a growing number of scientifically better educated specialists within the AMA membership confronted a shrinking number of less scientifically oriented physicians. Many of the latter had, however, in practice become de facto general physicians, some of whom learned from their exposure in practice with patients to add a humanistic and social insight to their repertoire for treatment of patients.
In any case, faced by the resulting dissension within the membership of the AMA, the leadership chose to bring a majority of non-physicians as adjudicators and peacemakers in to the ranks of the Millis Commission. Despite this disagreement within the AMA, the instructions to the Commission were explicit: that the Commission’s report was to go to the American Medical Association through its board of trustees and, in the same form, to the medical profession in general; as well as to universities, medical schools, hospitals and their trustees, and to legislators. In many intensive two-day sessions over a period of three years, the Millis Commission met with practicing physicians of many kinds, medical school deans and faculty, hospital directors, and others associated with the delivery of medical care.
The Millis Commission had made two very important recommendations. One was that, in addition to the existing multi-year programs in graduate education for training of physicians in the existing numerous medical specialties, the medical schools should develop on a par with them a program for physicians educated to deliver to patients what it chose to call primary medicine — that is, physicians educated to provide continuous and comprehensive care of patients with an emphasis on preventive actions as well as curative therapies.
The other fundamental recommendation of the Millis Commission was to address the need to develop, especially for primary medicine, a new body of knowledge to add to that principally biological knowledge which had been developed for the existing specialist education. That small number of surviving early pioneers in primary care medicine will appreciate, I think, these words from the Millis Commission:
“The good primary physicians now in practice have acquired much of their skill and wisdom from experience or from intuition. What is needed — and what the medical school and teaching hospitals must try to develop — is a body of information and general principles concerning man as a whole and man in society that will provide an intellectual framework into which the lessons of practical experience can be fitted. This background will be partly biological, but partly it will be social and humanistic for it will deal with man as a total, complex, integrated social being.
This background (as we all well know) is not now well developed. Clearly, there must be a considerable amount of experimentation on the part of schools of medicine and teaching hospitals in efforts to arrive at the most satisfactory subject matter and methods of teaching. The immediately important thing is to have a clear and definite resolve to impart this new body of knowledge. The rest will follow.”
This audience will think of some heroic, indeed heretical, physicians who have striven to add this psychosocial dimension to the established biomedical concern with the vulnerabilities of the human body. We can have reason to be grateful to them as well as to physicians and surgeons who have dealt with our body disorders. I should testify, as a critic in some ways of medicine, to say that I am a beneficiary of some remarkable fine biological interventions in my own body, beginning with the five by-pass heart, a by-pass in my right leg so I am still standing on it, and a carotid artery reamed out not too long ago. So I am grateful for biomedicine on these occasions, I assure you.
We should be aware in our contemporary culture, thought, of a pervasive, dominant, but constricted view of the world around us. And I say these words in order to console physicians if I seem critical. I am referring namely in our culture to the dominant preoccupation of current generations with science. Well, what do we mean by that? A science not about man, but about nature; about things and technology; science and technology proudly resonating together.
But what about attention to human nature, to man as a remarkably social species and at the same time as a remarkably unique individual? Think for a moment of what the founding fathers of our republic two centuries ago worried so much about and strove to construct: the establishment of a common framework for the necessary government of a peaceable society which would include the maximum freedom possible for the individual. They were not just talking; they worked to create the base for a kinder, gentler society in the Constitution of the United States and the Declaration of Human Rights.
Medicine is not the only profession to suffer in the name of science from a reduced perspective on man. Let me call to your attention a book published in 1986 entitled, Tradeoff: Imperatives of Choice in a High-Tech World by Edward Wenk, a highly educated and innovative engineer who in 1959, became the first science and technology advisor to Congress and who then served on the science advisory staffs of presidents Kennedy, Johnson, and Nixon. At the end of the 1960s, he came to the University of Washington as Professor and Public Affairs. As he stated in his book about technology:
“We arrive at a striking conclusion: technology delivery systems are not mechanisms. They are organisms.”
For Wenk, they have manifold consequences for man and society. Therefore, he affirms that the engineers who produce technologies must be educated not only in the sciences but also in the humanities and social sciences so that they may become aware of the consequences of their technologies for mankind.
The leaders of corporations and the business world in general are also being reminded in national journals like Time and Fortune to develop a new approach to the production of their products and services by focusing their attention not only on technology but also much more on people. Surprisingly, maybe even on the likes and dislikes of the people who are purchasers of their products and services. They should overhaul, also, their management strategies from the typical top down supervision to include consultation with all their workers from the bottom to the top of the employee hierarchy. They should consult all levels of their workers about specific procedures and method changes that would contribute to potential improvements in quality and efficiency of production of their goods and services.
This is in short a rather remarkable proposition that you should actually consult people about how they make things and how they like what they make, and want to improve it in some fashion or other. In its issue of August 12, 1991, Fortune describes how the chairman of General Electric has changed the management of that company by tapping the brainpower of its employees with promising results. In its September 23, 1991 issue, the same journal has an article headed, “Nothing Is Impossible: You can meet any challenge if you recognize a shift in the paradigm. Ready to throw out the old rules?” Paradigm may be a new buzzword to business, but not to medicine, which now stands in need of a substantially expanded paradigm.
While the biomedical paradigm still dominates a large proportion of the physicians in the United States, I recognize that this audience includes many who are already biopsycho-social heretics, dedicated to continuing a biological base for medicine along with the psychosocial base. There still remains that dominant majority, however, of specialty oriented physicians who, it is to be hoped, will not resist the emergence of a growing number of primary physicians to meet the full range of needs presented by the patient population.
Unfortunately, the latest figures available from the AAMC studies of the medical student population show that the percentage of medical student seniors who plan to seek certification in primary care — that is family practice, general internal medicine, and general pediatrics — has fallen from 37% in 1986 to 23.6% in 1989. We should be getting the very latest figures quite soon, I would think. This unfortunate trend can only serve to invigorate a more strenuous effort to recruit a larger corps of primary physicians to treat the full range of medical problems presented by the American population.
A serious impediment to success in this regard is the fact that the current body of primary physicians in this country is itself — let’s face it — a house divided into three different models: family physicians, general internists, and general pediatricians. Each has separate boards, separate associations and meetings, separate journals, and, frequently within medical school faculties, separate departmental niches. These structural arrangements certainly do not increase the chances for the three heretical brands of primary physicians to persuade the present orthodox specialty physician majority to accept the wider cognitive paradigm required to meet the range of medical problems presented by the diverse patient majority in need of the help of physicians.
I am pleased, however, to be able to c all to your attention some promising beginnings of collaboration among the three existing primary physician groups. We have heard some references to this subject in this particular gathering. In 1986, the Kaiser Foundation published my book entitled Dear Doctors: A Personal Letter to a Physician, in which I have tried to tell doctors the risks they were running with the kind of education they had received which needed modification. Its recommendations were discussed at a conference held in 1987 in Wickenburg, Arizona, and were subsequently described by Kerr White in his book entitled The Task of Medicine: Dialogue at Wickenburg, published by the Kaiser Foundation in 1988.
I happen to be very encouraged by some of the interaction which occurred at Wickenburg in conversations with the members of the different “brands” of primary medicine. I had subsequent conversations with Dr. Alvin Tarlov, then president of the Kaiser Foundation about this and received some generous financial assistance by which I was able to arrange, ultimately, for some activities: first, a two-day session in St. Louis in December, 1987, followed by another one in February, 1988. These were attended by the then presidents and two other prominent members of three primary physician associations — the Society of Teachers of Family Medicine [STFM], the Society of General Internal Medicine [SGIM], and the Ambulatory Pediatric Association [APA].
These meetings ended with agreement on the desirability of more collaboration among the three groups after interesting, informative, and historic interchanges in the course of those four days of meetings in which it was abundantly clear that the beginnings of these associations had not been on what you would call “a very friendly basis”. This is historic background which I am sure some of you are very familiar with — maybe all of you. But, by the end there was a realization that they also shared some common ground. They ended in agreement on the desirability of more collaboration among these three primary care groups.
As a consequence, when the SGIM Task Force on Doctor and Patient sponsored its annual conference on the medical interview held later in 1988 at Harvard Medical School, family physicians and general pediatricians were participants, along with general internists. Similarly, in March, 1989, STFM arranged for the presence of general internists and general pediatricians at its Ninth Annual Conference on the Family in Family Medicine, held in Amelia Island, Florida. In that meeting the context of doctor and patient in an interview was expanded to include perspectives on the family members and their influence on both doctor and patient.
Both family medicine and general internal medicine have been developing an expanded cognitive base and relevant pedagogical skills for teaching about the behaviors and interaction among the three types of participants: doctors, patients, and family members, all of whom may be involved in the medical interview. I should emphasize to you that when the generalists showed up at the family medicine meetings, they were enormously impressed by the enrichment of the approach to the problem of relations between doctor and patient which came from the way in which the family was put into the picture and, above all, I would add, the family of the doctor was put into the picture. I have often regarded medical education as the cruelest form of education of the university curriculum in the United States as far as its own students are concerned.
I am very pleased to be able to call your attention to a further step in collaboration which will permit general pediatricians to share their insights into child development — a remarkably complex subject — with general internists and family physicians. General internists have already shared their insights into the doctor-patient relationship developed in the patient interview with family physicians, and, in turn, they have learned from family physicians more about the family nexus. In the Tenth Annual Conference on Teaching Medical Interviewing, to be held in June, 1992 at the Boston University School of Medicine, general pediatricians will now be actively contributing their perspectives on child development as it influences primary care situations confronted by physicians. It is very interesting that in the flyer right on the front page is a reference to child development and a new focus at this next meeting of that annual faculty development course on the interview.
I would like to close with this commentary on problems and prospects for primary physi-cians, with reference to another setting — apart from the annual and regional meetings of the three national associations of primary care physicians — in which progress is being made in collaborative developments which could increase the cognitive base for primary care and the clinical skills of the three primary physician groups.
Within many medical schools there are now three separated small groups — family physicians, internists, and general pediatricians. These faculty members, still relatively small in numbers, are generally surrounded in most medical schools by a great majority of biomedical specialist faculty who are primarily engaged in reproducing themselves in the oncoming student generation, totally out of phase with the numbers in the stories which we heard this morning from the federal government activities. [See the transcription of the remarks of David N. Sundwall, MD and Marc Rivo, MD “The Revitalized Role of the Federal Government in Health Care”, Third National Conference on Primary Health Care Access].
The present national concern with the status of health care delivery services in the United States may well lead to pressure from outside the medical profession for change, but it is surely devoutly to be hoped that voices will be raised within medical school faculties on behalf of an improved balance between primary and specialty physicians. As a first step in forging a constructive response within the profession to address the current imbalance, enterprising individuals from the existing primary care groups should undertake collaborative networking among themselves to develop joint programs for the education of physicians within their own medical schools.
Within a particular medical school, joint representatives of the three primary care disciplines should collaborate in developing a major required course for all medical students in the social roles and responsibilities of physicians in primary care practice. They could, indeed, networking among themselves, develop model community-based resident rotations in primary care. They could organize the editorship of a yearbook in primary care research. They could develop an exemplary curriculum in physician-patient communication. They could develop an undergraduate-graduate curriculum in cost-effective medical practice and practice management for primary care gatekeepers and managed care programs.
Admittedly, in medical schools the number of existing primary physician faculty are often too few to exercise a large influence on the entire medical faculty. But if these small groups are to exert a larger influence on medical schools, they could certainly be greatly helped by the availability of external financial support for increased networking among themselves on their own campus to expand the biopsychosocial knowledge base and the relevant teaching and practicing stills for the delivery of primary care to patients. I am delighted, therefore, to be able to call to your attention some things you may have seen also recently as possible sources of financial assistance for such networking within a particular campus.
For well over a decade, the Robert Wood Johnson Foundation has been funding its Clinical Scholars Program which has enabled fully certified younger physicians to add humanistic and social perspectives to their approach to medicine. In February, the Foundation announced a new program, its General Physicians for the Future, which will address changes in the medical education system which would be favorable to the prospects for primary care within medical schools.
There is some indication that the Kellogg Foundation may also be interested in this kind of thing. Thus, there will be new opportunities for energetic and competent primary care leaders in the development and evolution of programs for more well educated practitioners of primary medicine. Given the mounting public concern about deficiencies and opportunities for health care in the nation and the evident participation of governmental officials responsible for our nation’s health in this very meeting, it is possible to hope, also for governmental support for initiatives for primary care.
By an accident of fate, I can also report to you an unusual curricular initiative on behalf of primary care within a medical school which has a long history of producing many specialist physicians. Three weeks ago I completed a three-year term as a member of the visiting committee of the University of Michigan Medical Center. Much of our time was devoted to an extensive description of a process of development of a total review and revision of the four year undergraduate curriculum at the University of Michigan, initiated by what I can conceive of only as a most courageous dean with the participation of well organized faculty committees which has ultimately been approved — as of last October I believe — by the executive faculty of the medical school of the University of Michigan.
I wish that it were possible for me to have a digest of what I have learned about that effort. I can only say that one of the things which I think the general physicians represented by persons in this room could do, would be to look into that program to see the way in which the whole four year sequence is fundamentally added to and altered. It begins in Week One, when the MD candidate arrives the first time at the University of Michigan medical campus. Over the four years, every Wednesday afternoon is blocked out totally for doctor and patient, which is the topic under which a whole host of things having to do with medical practice will be presented to the students.
It’s a complex program. It has evolved with a succession of faculty committees that have been set up to do this. A faculty retreat was held. When the time came to face the adoption of a fundamentally altered program with a constant reference throughout of the need for primary care, the decision of the faculty, I understand, was by a very large majority in favor of this very substantial alteration in the undergraduate medical program at the University of Michigan Medical School.
It is obviously a complex document. I call your attention to the fact that the Dean was appointed initially as an acting dean. In the course of his actions, they knocked the “acting” off. He is, you would say, a card-carrying specialist physician in background, but he clearly is convinced that the school has to produce a sizable core of primary physicians. He took the lead in appointing a general committee first and now there is a very interesting and complex committee structure which has been produced to work on the different sections.
I cannot give you any of the details, but he has told me at my request, that I should feel free to talk about it. I think it might be possible for you to get copies from him of this program, if you would like to see what a revived way of getting at the issue of primary care proposed there might have applicability in your institutions. What I want to say, then, is if we talk about more coordination and collaboration among the three primary care groups, that I think they would have a better chance united of getting somewhere than by playing the game separately. I would urge you to do what you can to learn about this new program and you will see the way in which primary medicine is constantly referred to in the documents.
The Twentieth Century, certainly, has provided us in biomedicine a great step forward over the deficiencies of earlier medicine. But this Old Testament desperately needs, in addition, the New Testament we have been hearing about in this meeting, a psychosocial addition to round out a biopsychosocial medicine. What we need in the United States, then, is access for all Americans to a medical establishment which is prepared to offer through an appro-priate combination of competent primary and specialty physicians to provide care for the entire range of ills which afflict the American people.
As the Twenty-First Century approaches, it seems reasonable to hope that there may be an abatement of the kind of institutional and personal arrogance which has accompanied the evolution of biomedicine in this last century. Hopefully, it will give way in the nearby next century to a broader, kinder, gentler medicine prepared to address the full range of challenges to continued healthy living as well as dying, which are confronted by patients when they turn for help to physicians.
Doctor Arradondo: There is time for a question of Doctor Odegaard.
Gene Kallenberg, MD, George Washington University, Washington, DC How many other medical schools are engaged in an equally extensive curriculum review to that which you described at the University of Michigan? The new Robert Wood Johnson request for proposals obviously will stimulate new activities, but are there medical schools you know about that have also already launched such approaches?
Dr. Odegaard: This is the first one that I have seen. I will have to say that there may be many of them around that I haven’t seen. But this is the first one that I have seen that lays out so clearly a large block of time and which has made constant references to the objectives of primary care. I don’t think they need to emphasize the high specialty care. They have loads of that there. But I think it is an energetic and good faith effort which seems to have developed a very considerable response from the general faculty.
I think that the dean beforehand had put together a series of faculty committees on different segments. So when they finally had a faculty retreat, I think there were a sizable number of persons who had participated in this preparatory activity who then, in a general meeting, could speak. I think this is what helped bring in the large level of support. You have to face the fact that the University of Michigan was certainly a temple of high specialty medicine of very considerable strength and size.
Dr. Arradondo: Thank you very much. We will have Doctor Odegaard’s presentation printed for next year so that you will have it in your registration package.