Proceedings of the 8th National Conference: Doctor Lynn P. Carmichael Delivers the Seventh G. Gayle Stephens Lecture

 

April 2, 1998

Dr Marian Bishop introduces Doctor Lynn P. Carmichael, the seventh G. Gayle Stephens Lecturer:

 

F. MARIAN BISHOP Ph.D.

Marian Bishop, Ph.D, MSPH, University of Utah: When the family medicine residency programs were first being accredited at the end of the 1960s, Doctor Lynn Carmichael and Lee Blanchard split the country – Lee did the west part, Lynn did the east part. That is when I first met Lynn and Lee who were those “paid” sort of staff, who went out and started these new exciting family practice residencies, and who founded the Society of Teachers of Family Medicine [STFM].

Lynn was the first STFM president, He was the founding editor of Family Medicine, which is the official journal for the Society of Teachers of Family Medicine. Guess who commissioned the STFM logo – that little family on the pin we all wear?  Lynn! He had a patient who designed it, and he had some of them made for friends. We liked it so much that he gave the patent to STFM and that is where the logo came from.

Lynn was the first University of Miami faculty member to be elected as a senior member of the Institute of Medicine. He is the winner of the Pew Commission Achievement Award for outstanding contribution to medical education. He is the winner of the Tom Johnson award for contribution for family medicine education. He is the winner of the STFM award for achievement in medical family medicine education. He served in the Armed Forces during the Korean War and received numerous awards.

Now with all of this, it is sort of surprising that he has remained a practicing family physician during all this time. His retirement last April (1997) was a fabulous event. And from that event came a booklet, which is called “Caring for the Family: A Village Affair”

I just want to read two brief comments from it, because I believe this sort of encapsulates Lynn. The first one is “One would think that a man of brilliant talents such as Lynn P. Carmichael would be raised up among the social elite of the world, and never again look back to help others with such diverse needs. This is a man of honor, who not only looked back, but went back, and stayed back to help everyone.”

Second: “With a bashful smile and an open mind, Lynn Carmichael has time and time again set new records in medicine, and has opened and closed medical history books for doing and achieving the impossible. Yet from his ingenious strokes of wisdom, he still often regards them as simple daily tests, and we know they are far from that”.

Please join me in welcoming Lynn as the father of academic family medicine. His talk is entitled “The Once and Future Generalist”. Thanks.

Applause

Dr Lynn P. Carmichael, University of Miami: I want to thank Bill Burnett for inviting me and I particularly want to thank Marian Bishop for that recognition. That was really unusual.  I am particularly pleased to be asked to give this lecture in the name of Doctor Gayle Stephens.

Lynn P. Carmichael, MD

Gayle and I met in 1967 when Lee Blanchard and I were going around the country trying to identify places that we could start family practice residencies, One of the requirements to have an approved residency was to be approved by the Accrediting Council on Graduate Medical Education [ACGME] (maybe it was the Health CME at that time, I can’t remember, the initials change.)

We had to have at least 16 residencies in existence in order to be considered as a specialty. So Lee and I went around and tried to identify people who were doing things that would help us get to that number.

We identified Gayle as one of those people, and I think having people like Gayle and others among those first 16 programs is what made it happen, so we are very grateful to Gayle for that. Gayle is really a very talented individual. He is a resource of wisdom, he is a philosopher, he is a futurist, he is an organizer, he is a major contributor to family medicine literature, and he is also brave. You know how I know he’s brave? He brought Dr. Marian Bishop to Huntsville, to the medical school.

Gayle Stephens, MD, University of Alabama, Birmingham: And I never was the same after this.  (Laughter).

Dr Carmichael: I think the other thing about him is that he is a wonderful person. He is our national treasure as far as family medicine goes. I can identify a couple of other national treasures, but not of this nation. One is Doctor Ian McWhinney of Canada, and the other is Brad Grey of Great Britain.

To prepare for this talk, I changed it a little bit. I think the title is still applicable. What I decided to do was re-read the publications that Gayle Stephens had written, and I read more than a dozen that went over a period of 20 years, from the early 1970s to the early 1990’s.  I tried to select themes relating to generalism and its development. I wanted to review from the perspective of where we are and where we are going.

I will mix my thoughts with Gayle’s predictions of the future. Gayle has told us that patient management is not just diagnosis and treatment – it is an art, and science, and quintessential skill of a clinician. He sees family medicine as counter-culture – a movement bigger than itself. He lists pediatrics and psychiatry as valued predecessors.

I would agree, but they have strayed from the fold lately, and increasingly are working with and serving those medical enterprises.  I imagine Gayle shares my disappointment with their clinical zeal – their medicalization is almost complete.  Here I am referring to Ivan Illich’s book “The Medical Nemesis”. Gayle, did you ever think that the industrialization of medicine would ever go so far? It’s incredible.

I believe that Carl Wright coined the term Primary Care in the late 60’s When you use the term Primary, secondary, and tertiary care, he was categorizing health care according to where clinicians worked. Large hospitals with wide capabilities were tertiary; local hospitals and specialty resources are secondary, and everything else that was left over is primary care.

The Institute of Medicine report “Primary Care: America’s Health in a New Era”, issued in 1996, does not seem to have made much of an impact. In a  sense, primary care is where we work, not what we do. I feel that very strongly.

I think “primary care” is a lousy term and is prejudicial against people who do a lot for people’s health, but are not physicians. Most of those people work in the primary care sector, and we need to include them in that definition.

Gayle has wrestled with the various terms: “general practitioner”, “family practice”, and “family medicine”. To me, the generic term is the “generalist practitioner”.

My definition of the re-born GP is as follows. A Generalist Practitioner is a health care professional who is responsible to a defined constituency; and that constituency is the denominator of the people they care for, not the numerator. The idea is to insure that constituency that they will receive appropriate care for an optimal outcome.

Now, let me talk a little bit more about this. First, a generalist does not limit care or services. In other words, anybody that comes to see you, you take care of. I read someplace that somebody did define what they did as a generalist by saying “I limit my practice to the diseases of the skin and all of its contents”. (Laughter). Anything goes, you got a flat tire, you can tell your GP about it.

Second, constituencies – I’m using the word constituencies rather than panel. Constituencies is a political term and it means that people have rights. I think it is very important to drive home that people really do have rights in health care. And I’m going to talk a little bit more about this later.

Appropriate care is what the practitioner advises, so, the optimal outcome is what the patient wants. Therefore, the job of the practitioner is to tailor that care, of whatever kind it might be, to meet what the patient’s desires are.

(Parenthetically, I have a problem with the use of the word patient – by definition a patient is sick. Most of my practice constituency are not ill, so I should do what I can to preserve their health. I have tried to use the word “patron”. Patron is a pretty good word, and “person” is also. While the terms patron or person are awkward, they better define the population to whom I am responsible. I would like to move away from the concept of patients and patient care, because we are now doing a great deal, and need to do a great deal more, to keep people from actually becoming patients.)

We can do that now, because we now have access to the denominator. You don’t have to wait for a woman to come in and then suggest that she have a mammogram. You can reach out in your practice and identify those people that need various types of services – preventative services, health education and so forth. I think that a lot of the developments in technology are going to help this.

Gayle has urged the AAFP to expand its membership beyond physicians, and I would encourage this. When the Society of Teachers of Family Medicine was formed, membership was not restricted to physicians. At the present time, and over periods of time, 20 percent or even more of the members have been non-medical doctors.

Later this month, in Chicago, the STFM is going to vote on a mission statement. In this statement of vision and goals, they on two occasions refer to physicians only. Those of us who are going to the STFM meeting should object to that. I think that is what Gayle is saying as far as with the Academy membership. You need to move with a broader mission so that you can better deliver the care that people need.

Gayle has expressed his concern over “high tech” medicine, and I agree.  Technology should be the means and not the ends of health care. I think that realizing that technology is a means, we can use those means in the community very well. The technology that has been developed creates lots of opportunities for us.

In the current New Yorker magazine, there is a delightful article by a physician named Atoul Gawarnde. The title of his article is “No Mistake – The Future (of Medicine?) of Machines That Act Like Doctors and Doctors That Act Like Machines.” I’ll close this part with a little quote from what he said: “In the increasing tangled web of experts, and expert systems, the primary care doctor has the obligation and the opportunity to take on the role of the patient’s knowledgeable guide, contractor, and confidante. Maybe machines can decide, but only doctors can heal.”

Now, I think really only people heal. They heal themselves, but we may enhance that. He used the “PCP” term – I find that a very disagreeable term – but I guess that depends on how you do it. Most of the people talk about it being a “primary care physician”, and I would accept it if they would talk about it being a “Personal Care Practitioner”.

The next thing I want to get into –  again, Gayle has written about this, maybe not quite in these terms, but I am going to be a little more blunt – is the corruption of academic medicine. I think that it is breaking down because of their interest in power, money, elitism, hubris, and now dishonesty and greed.

The current JAMA has an article on the murky relationship between corporations that give gifts and the researchers who receive them. The New England Journal a month or two ago reported that researchers who were supported by drug companies reported positive results with calcium channel blockers, and the studies of those that did not have such relationships showed negative benefits. Those who did not have drug company support found that the calcium channel blockers are really pretty dangerous and need to be used very carefully.

Gayle has written that we should give the finger to the medical schools. I have a different solution. I propose that we undertake medical education at two different sites. One would be the academic health center, and the other the community.

This location in the community, I would like to call the primary care campus, not the academic health center, but the primary care campus, and it would be in equal importance to that Academic Health Center, in that, half of the medical students, half of medical school teaching would occur in the Primary Care Campus, and the bulk of Graduate Medical Training for generalist, would occur there.

As Generalists, I am talking about family practitioners, general internists, community pediatricians, most psychiatrists, preventive medicine, and OB/GYN. The specialists would also have some of their training there.

Copies of the original “Essentials for Family Practice” that Lee Blanchard and I put together have been passed out to those of you in the audeince. aThe Essentials have been revised repeatedly over the years by the Residency Review committee and now faces its demise because of the “hardening of the categories” that have developed.

I’m going to talk a little bit later about the “Essentials”. We sort of start out this way when we were getting going almost 40 years ago, and it’s been washed away quite a bit since then.

The primary care campus, where we work, would be one without walls. The ramifications and benefit to the denominator – to those people we’re looking after, would be extraordinary. I would dearly appreciate your thoughts and suggestions. Perhaps we should arrange a working conference on the primary care campus of the most wonderful school of medicine in the United States.

We need to encourage flexibility and particularly need to dump the family practice center. It may be surprising I would say that because I was probably the most prominent advocate for it, but it is not real. It doesn’t work very well, and I think where it doesn’t work very well is particularly those family medicine programs that are affiliated with a medical school.

I think when you get to a community hospital, it may be a lot different. Rather than requiring so many hours or weeks of a given specialty or site, I would suggest that accreditation be based not on that, but on how they learn and are taught prevention, treatment procedures, and continuity. I raised this at a RAP (Residency Assistance Program) meeting 15 years ago, and you know what happened? I got rapped. (Laughter)

I suggest we make common cause with other health professionals. I believe that we should have done this a long time ago, starting with osteopathy. The New York Times, on February the 17th, had an article on the burgeoning growth of osteopathy. I think we have a great deal in common and a lot to learn from them, beyond manipulation, and I am looking forward to Dr. Thomas Allen’s speech tomorrow.

Others that I would include in this, other than the generalist physicians, would be nurse practitioners, nurse midwives, physician assistants, optometrists (Did you know, that 50 percent of the people in the United States have never had their eyes examined with a slit lamp? Why is that? The cost of this neglect to us is so great, because of the disease – retinopathy – that occurs.

If you want to go to an ophthalmologist, you have to seek one out. They are usually at the secondary, or tertiary level. Certainly, an optometrist can recognize the symptoms of retinopathy. They  have the equipment and know how to use it. We could arrange for such a diagnosis from one, and can walk people over to them, right in the same setting.

For many years, I’ve worked with counselors and psychologists, who’ve been very kind. It is so useful to have them right in the same place, because then you can walk people over to them. Once you try to make a referral to a psychiatrist, you have about an 80 percent failure rate.

So, working together, and I’m not talking about individuals here, I’m talking about a team effort, that we all get together, and work in these joint practice sites, and I think they should be, as was mentioned earlier, not-for-profit type of situations. I think that would be ideal.

I think if we develop a team approach to manage both prevention and treatment, as well as training generalists in these settings. Gayle speaks of “personal medicine”, as a title of one of his articles, “The Best Ideal in Family Practice”.  Ian McWhinney, another one of those giants, writes about “patient-centered medicine”. I believe they are both describing the same thing (although I still prefer the term “personal medicine” as being more consistent with the definition of a generalist practitioner).

Gayle, Ian, and Dennis Perrier Gray are our International treasures. Gray had a superb article in the January 1998 issue of Lancet, where he took evidenced-based medicine, with emphasis on personal significance juxtapositioned with statistical and clinical significance.

He really had helped me a great deal to adjust to this new kid on the block, evidenced –based medicine. I think I felt intuitively that there was something there missing, and what he is saying what is there is this personal, or patient/clinical significance with the individual.

Ian McWhinney, writing in the Annals of Internal Medicine (which is kind of an unusual thing to do), about a year ago wrote an article “Rethinking Somatization”. He and his colleagues actually destroyed the specialist who believed that disease has an existence of its own.

Specialists really do believe that. They do believe that they can treat hypertension. They are not interested in the person, they are interested in that disease. The person is left out of it, as the person is left out of the treatments of most of the specialties. All you have to do is treat the hypertension and the people will be all right.

However, what you really do is treat the people who have the hypertension. I’m personally not interested in disease, I don’t want my people to be sick. I want to do what I can to keep them from it. I think “academic medicine” is at least partially responsible for this.

I’m going to shift gears now and talk about the rights of persons in health care. Every resident in the United States and its possessions should have open access to health care. There are a number of reasons in favor of this, but I will list just one. That is, unless we have a truly healthy population, the United States will not be able to compete with the other industrial societies. We’ve got to get over that hurdle so we can make our country well enough to be educated and to work.

Based on my 33 years in academic medicine, I’ve often wondered why it costs so much, almost twice as much, to give poor care to the poor. I believe that academic medicine is at least partially responsible for this, because academic medical centers depend upon the indigent. I guess what I’m saying is that medical schools are one of our reasons that we still have uninsured, uncovered individuals.

And why does this happen? Very, very clearly – income. Dollars flow when you do that. The dollars pay for the training of residents – residents who are the slaves that cover for the academic physicians on nights and weekends, and whose notes they forget to countersign, so that the residents get slapped down by the feds on that.

The other thing that’s nice for academic medicine is that we can always depend upon the poor to be the research subjects. I think, that on the basis of all this, and on the information that was given to us earlier about academic health centers, I think that academic health centers have become cost centers, not profit centers.

The rights of patients are incredibly important, and there’s a man named Charles Fried, who wrote about the rights of individuals in health care, that sounds very good.

The AMA came out with what I like to call the “medical Miranda”. If you’ll read this to the individual who you are taking care of, then you can go ahead and do what you want to, if you get consent. President Clinton’s Patient Bill of Rights looks good, but may become the Specialists’ retirement fund. (I would appreciate it if Peter Lee Esquire could comment on this afterwards.)

And I am going to now close, and I want to thank you again for the opportunity to talk with you. I particularly, dearly love Gayle, and to have this opportunity is highly appreciated. I’m going to quote from a book he’s also read, called “The Fortunate Man”, and this is the last paragraph in it. It says: “Sasall is never the less a man doing what he wants, or to be more accurate, a man pursuing what he wishes to pursue. Sometimes the pursuit involves strain and disappointment, but in itself, it is his unique source of satisfaction. Like an artist, or like anyone else, who believes his work justifies his life, Sasall, by our society’s miserable standards, is a fortunate man. It’s easy to criticize him. One can criticize him for ignoring politics.

If he is so concerned with the lives of his patients, in a general as well as a medical sense, why does he not see the necessity for political action to improve or defend their lives? One can criticize him for practicing alone, instead of joining in a group practice or working in a health center. If he is not an outdated 19th century romantic, with his ideal of a single personal responsibility, and in the last analysis, is not this ideal a form of paternalism?

He himself is aware of the implications of criticisms. “I sometimes wonder, he says, how much of me is the last of the old traditional country doctor, and how much of me is the doctor of the future. Can you be both?”’ I know, from personal experience, that Gayle Stephens is a very fine doctor, and I think this probably expresses some of his feelings at this time. Again, thank you so much.  (Extended Applause).

Bill, I’m not getting the signals. What are the marching orders?

John Payne, MD, University of California Davis/Stanislaus Medical Center Family Medicine Residency, Modesto: I am very interested in your comments on the worthlessness of the camily practice center, and I don’t respond defensively at all, but I would really like to have some comments from you on how we might change family practice centers, and family practice education.

Dr Carmichael: I guess maybe I’m overstressing the family practice center. What I was after was that that is the only place that the Residency Review Committee on Family Practice will allow the residents to be. And they have all these requirements and so forth. I think it was a good idea, since it may have been partially my idea, but in my experience it hasn’t worked out, and that also may be my responsibility.

I think being in a medical school makes it harder, but one of the things is, that ought to be the center of all the care and the teaching, it ought to all be there, and it’s really not.  I mean it’s okay to start off with a sort of internship type thing in the first year, but we need to give people more there.

What I saw happen repeatedly was when the residents were on an inpatient service, even our own inpatient service, they would defer to that, and not care for their patients. And that’s something that we need to teach. They learn that because they were, in my situation I think, because they were in an academic medical center.

I would like the family practice center to continue, but I would also to have other ways of setting up training programs that would give a lot more flexibility. It is so rigid, you’ve got to have these different things – and people, and circumstances, their communities and all that- they need different types of things, and it ought to be tailored to that. So, I may have, again, overstated but at least I got your attention. So, thank you.

Peter Lee, Jr, J.D.: I’m called upon to respond in terms of the Bill of Rights issue. I will respond briefly.  Dr Phil Lee noted that I was on the California Task Force on Managed Care, which was the California equivalent of the President’s Commission. There’s a lot of things called the Bill of Rights which are being bandied about.

The President’s Bill of Rights is different than a number of bills before Congress, that are much stronger than that, but I think your allusion is absolutely appropriate. A lot of things that are cast as Bill of Rights are using consumers as front people for different specialty interests, most often specialist physicians, but also, often, unions, sometimes employers, etc.

And a couple of things that I think that are incredibly important about patients’ rights, one that Phil mentioned, is about information. And it’s information not just to compare medical groups and products, but it’s also information that goes beyond the “medical Miranda”  (and I’ve not heard that term but I love it, as an attorney). The right to be fully informed about what are the care options you have is something I think that a lot of doctors jump over and don’t do enough. And I think the doctors that probably do it best are primary care family physicians, but I think they often still don’t do it very well.

We get a lot of calls at an advocacy program I run that are not problems with managed care, they’re problems with doctor-patient communications, and they’re problems with patients not understanding what their options are, and thinking they’ve been told no, etc. So, having the right to be truly informed, and what the options are, and what the options aren’t, and why you’re recommending something, is something that is coming back to your table.

The other is the right around what attorney’s call “due process”, is where you have a disagreement, having to work that out. This is a place where “physicians as advocates” is so important. Patients can’t advocate for themselves very effectively against a managed care plan. They need to have the support of their doctors, because the review panels are always going to be Utilization Review docs, and having that support is incredibly important.

So, all the laws, all the rules, are great, but in the end its going to come down to the doctor-patient relationship, and having good communication there and the support of the primary care physicians of their patients. So, I appreciated the question.

Pat Jonas, MD, Wright State University, Dayton, Ohio: I’m on the faculty of Wright state University. Some of the folklore from Tenny Williams, one of my teachers at Ohio State, had something to do with during the founding times of the lousy relationship that we had with Psychiatry, or something about the speaker of the house today. Could you comment on the truth or veracity of that so I can go back and clarify for Tenny what the reality might have been.

Dr Carmichael: Well, I’m not sure I clearly understood your questions.

Dr Jonas: Well, I don’t know either, that’s why I’m asking you if you can clarify what was our relationship with Psychiatry when we started all this? Our Specialty and our residency training and so forth?

Dr Carmichael: Gayle can ….

Dr Stephens: I hope you don’t mind (to Dr Carmicahel). Okay, so I’m Gayle Stephens, and we’re talking about Psychiatry and Family Practice at the beginning.  There is some very interesting history, which I won’t go into here, but the Mental Health committee of the Academy Family Physicians, was the most active committee, much more active than the Education Committee, which became, obviously, the more active committee.

There was actually a grant between the APA, there was a program, between the APA and the AAGP for teaching psychotherapy to General Practitioners. This was funded by the National Institutes of Mental Health. It turned out that the officers of the Academy were the only ones who ever got to participate in this and they would have these wonderful meetings with the psychiatrists from the Menninger clinic in Topeka, Kansas.

And they would go home and talk about all they learned, about how to treat depression. Really it was how to do psychotherapy. So there was a strong relationship, a strong working relationship between the APA and the Academy, which I think got fouled up a bit with the introduction of behavioral sciences.

The psychiatrists thought we were, pardon the expression, gone “a-whoring” to find other people who could do psychotherapy, besides psychiatrists. I was put on the spot once by them. Child psychiatrists were particularly offended, by us, because we did not ask them to do or to teach us how to do, with all this talk about family, and child rearing, and that sort of thing, and we were bypassing the child psychiatrists.

They were the ones who were most offended. Then, I think psychiatry as a whole, the APA, sort of abandoned the psychotherapeutic model in favor of the psychopharmacologic model, and went back to the hospital and got interested in coronary care units and the burn units and the whole thing kind of dissipated.

On a more fundamental level, I think the family practice center, Lynn, is an analog of the community mental health center, which we inherited. Family physicians inherited the mantle of unrealizable, romantic expectations which came out of the mental health movement. If you look at what was happening under the Eisenhower administration, the concern with mental health, the community mental health center was going to be the place that revolutionized mental health care for the country.

This came out of World War II. The psychiatrists abandoned the community mental health centers almost as soon as they were created. There were these huge battles over who was going to be the managers, and the psychiatrists were actually pushed into the role of drug pushers who would go to visit the mental health center one day a week, and somebody else ran the mental health center.

Well, I think we got the mantle of expectation, public expectations, that we were going to do in the family practice center. Everything that was going to go on in the community mental health center, and plus.  And of course, we didn’t do that. So, I do believe that there is an interesting history here. I took the trouble once to go through all of the minutes of the Committee on Mental Health of the AAFP, as well as the minutes of the Commission on Education, which was the Committee on Education.

When the family practice residency program along, the Mental Health Committee became concerned with the mental health of physicians, and the education commission got a commission status, and got a full time director, Tom Johnson, and was going to develop a residency. So I think there was some kind of unrequited love affair, that is still unrequited. (laughter).

John Bradley, Southern Illinois University, Decatur Family Medicine Residency Program: I’m not sure who this question is for, so I’m just going to ask it, and I’m not sure what the question is, but I’m going to try. When Family Practice was invented, and since we have some inventors in the room – the bases on which it was invented – was any of that empiric? And by that I mean, did we ask patients, or people, or the public at large what they wanted, specifically, or did we do it, kind of, all on our own? I guess that’s the essence of the question and that’s for anybody.

Dr Carmichael: Speaking for myself only, I think I learned a great deal in the first ten years I was in practice, most of which was solo practice. And I felt that this was a very necessary thing. I really did not ask my patients, but the patients, the people that I saw, seemed to really do well with this. And that was sort of it.  As far as I know, there never was a citizen’s group that was involved in the establishment of this, and it was through medical organizations that it happened.  Do you know, Gayle?

Dr Stephens: Our kindest critic is Ed Pellegrino, who was at Kentucky when a lot of these ideas were being worked out. Ed Pellegrino said that we were mutants – I mean he uses that word – that we created ourselves. We were based on general practice, but we got concerned with more than the public wanted, and that was family medicine. I mean the public was not asking, say for family therapy, and the family practice center, was not asking for anything other than ordinary medical care at reasonable cost at accessible times.

And what we designed was a package that we were interested in, and he described us as mutants. Now Ed had no particular love for general practice, but he saw us in our evolution, and I feel sure he said this kindly, I mean I’ve heard him say it, and I believe he was kind, is whether we were going to continue to evolve as mutants, or whether we were going to become revisionists, which he would see equally bad as going back to general practice at its paternalistic worst, or whether we were going to find some middle in Primary Care.

And I think you could accumulate a good deal of data around all this. For instance, you know, we have blunted our sword on the word ‘Family’. Look what has happened to the evolution of the ideology of families, and the political deal around family values and all that stuff that has happened. You know, we just simply have blunted our sword on the family as a patient. We don’t do the family as a patient, we don’t even know how to do the family as a patient. And that was a much more loaded word, it seemed like a simple word, but it wasn’t a simple word.

So, I think we are evolving somewhere from this mutant stage, and then the proceduralists among us are the revisionists, the people recreating the procedural model of the family physician, or general practitioner, whether this is endoscopy or colposcopy, or whatever, which is a debate within our midst. Or whether we can see some kind of role as Lynn has described here, with the ideals around preventive medicine, and conversation, dialogue, or whether we have to kind of be one or the other. And I think we took the ball, and ran off with it as far as we could, and probably ran off into some wrong directions.

Dr Bradley: I think the answer to my question is no. (Laughter) Because what I see here, I think, we’re a group of thoughtful, experienced, but nonetheless, medically trained physicians who thought they saw a need and went out to address it, and that happened to coincide with a public movement.