Marcus Welby and the relentless growth of specialization

In the very first episode of the TV series Marcus Welby, MD, our hero delivers an after dinner speech to a group of young interns. As he’s introduced, he hastily scribbles the title of his talk and hands it to the hospital director: “The future of the general practice of medicine, if any.” The year was 1969.

In his introduction, the director somewhat tactlessly remarks that many “eminent specialists” have addressed the group in the past, but tonight they have a general practitioner.

After acknowledging this, Welby continues:

Don’t apologize, You’re right. That’s what everyone thinks. Tell me, doctors, are you a specialist or a GP? Or sometimes they say “or just a GP?” But of course we are specialists. And our specialty, like any other, has certain advantages and certain disadvantages. The money is good, but you have to work three times as hard for it. But you people know all about that.

Since you’re about to choose your specialty, you’ve been amassing information about each. Psychiatry, we know, is practiced sitting down. Dermatologists don’t make house calls.

General practice is performed standing up, sitting down, outdoors, indoors, wherever there’s illness. And that means everywhere. Because, gentlemen, we don’t treat fingers or skin or bones or skulls or lungs. We treat people. Entire human people …

… I hope some of you will go into general practice. For if you don’t, where will a patient turn who doesn’t know that he has an orthopedic problem? Or a neurological problem? Or a psychiatric problem? Or a nutritional problem? But who only knows that, in lay terms, he feels lousy.

I’ve been told I’m a dinosaur, simply unwilling to become extinct. Maybe I am. But perhaps you’ll remember that one of these after dinner chats was given by a moldy old fig, with overtones of megalomania. And that he almost convinced you to go into general practice. You’ll remember it, and you’ll look at your beautiful wife and your two beautiful cars and your beautiful barbeque pit and for maybe three seconds you’ll be sorry you didn’t take his advice. But then, a beautiful breeze off the ocean will restore you to sanity. And you will have missed a hell of a lot.

The relentless growth of specialization

Specialization in Western medicine began in the early 19th century, once the practice of medicine changed from balancing the humors of the body to diagnosing diseases in specific organs. By the late 19th century Americans were traveling to Germany to study the latest clinical discoveries. The US medical market was highly competitive — before the reform of medical education in 1910, anyone could hang out a shingle regardless of qualifications. So offering a specialty – obstetrics, ophthalmology, otolaryngology – as part of a general practice provided an edge.

Specialization grew relentlessly. In 1931, fewer than one out of five doctors was a specialist. By 1969, there were more than three times as many specialists as general practitioners.

Some of this increase was stimulated by forces outside the control of the medical profession. For example, doctors who served in World War II were classified into graded categories. A certified specialist was paid more and given a higher rank than a general practitioner who may have had more experience. The GI Bill (1944) provided four years of subsidized residency training, including a living allowance, increasing the number of specialists. This may have been a well deserved reward for those who had served their country, but it had nothing to do with the health care needs of the 1950s.

The promise of the sixties and seventies

Things began to look up for generalists in the 1960s. The term “primary care” was introduced in 1961. Following the creation of Medicare and Medicaid in 1965, the Folsom report recommended not only that every individual should have a personal physician, but that the status and income of those physicians should be comparable to that of specialists. Two American Medical Association reports in 1966 endorsed board certification of primary or family practitioners. In 1969, as Dr. Welby was giving his speech, the American Board of Family Practice was established.

Students who chose family medicine as a specialty in the 1970s were inspired to change the medical culture. The Public Health Service Act of the 1970s, along with private foundations, provided explicit support for training general internists and pediatricians. The Health Maintenance Organization Act (1973) encouraged the rapid growth of HMOs, which tried out the idea of primary care physicians as gatekeepers to specialists. But patients were used to exercising free choice and created a consumer backlash. The subsequent history of primary care has been cyclic and rocky at best.

The future of primary care, if any

Few physicians today seem satisfied with the current state of medical practice in the US, whether they’re classic “specialists” (surgeons), subspecialists (pediatric oncologists), or general specialists (family medicine, general intern, general pediatrician). Our patchwork health care system of competing private enterprises is difficult to control or reform. Primary care physicians in particular complain that there’s too little time to care adequately for patients, too much bureaucratic paperwork, and – just as in Welby’s time – lower incomes.

If one of today’s young and idealistic doctors gave an after dinner speech on “The future of primary care, if any,” she could still find some grounds for optimism, however. It might go like this:

Our current health care system was created at a time when most patients suffered from acute, often infectious conditions that needed immediate attention. That is no longer true today. The majority of our patients have modern “lifestyle” conditions: diabetes, obesity, coronary artery disease, lung cancer, strokes, chronic degenerative diseases.

In the past, it made sense to organize health care into subspecialties that would treat acute, current conditions. But the health of our patients has changed. By the time a patient needs an oncologist, a cardiologist, an endocrinologist, or a surgeon — in many of those cases it would be fair to say that medicine has failed that patient.

What we need today is to recognize the crucial importance of integrated primary care systems, as well as public health policies that acknowledge and address the social determinants of health. We must provide financial incentives that attract and reward high quality primary care practitioners – and give them the time they need to care for their patients. Our goal could then be to empower our patients and give them hope that they may never need to see a specialist.

Jan Henderson is a historian of medicine who blogs at The Health Culture.

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