On the 60th Anniversary of the South Carolina Academy of Family Physicians

Thank you for the privilege of serving as president of your Academy. It is an honor to follow in the footsteps of leaders like Dr. Neal Shealy, Dr. Hugh Morgan, and the eleven past presidents who are in attendance at this meeting.

I would like to take a moment to recognize a few members of my family—my brother Greg and his wife Terri; my sister, Cindy Burt, and my Mom, Lillian Cupstid—who all live in Lexington; also, my sons Derrick and Brandon who attend the College of Charleston; and my daughter Kristen from Charlotte. And of course my wife, Betty.

This Academy started out in 1948 as the South Carolina Chapter of the American Academy of General Practice. Sixty years—that seems too brief a history for a discipline with such ancient roots. The image of the family doctor seems timeless, but it is actually a recent development. As physician and essayist Lewis Thomas noted, the field of medicine is "the youngest science." And we might add, Family Medicine is among its youngest disciplines.

Family Medicine was born in the post-World War II era, just like many of us Baby Boomers. I suppose you could say our specialty is itself a Boomer, sharing with that generation many of the values that have shaped our society over the past six decades.

Family Medicine was born out of necessity. In the early 1930s, 4 out of 5 five physicians called themselves general practitioners, but that would soon change. There was rapid growth in specialization in the 30s and 40s, partly due to scientific advances, and indirectly due to government policy. For example, medical students could receive a draft deferment if they were pursuing postgraduate specialty training. There were no deferments for General Practitioners—because there were no residencies—and many GPs served on the front lines during World War II.

When these physicians of the Greatest Generation returned from the War, they found themselves outnumbered by specialists, and increasingly barred from hospital practice. Patients were flocking to specialists, drawn in by their prestige and their procedure-oriented approach. By 1946—the first year of the Baby Boom—the public, the government, and even the AMA had come to recognize that over-specialization was making medical care too impersonal, too institutional, and too expensive.

In response, the AMA established a section for General Practice leading to the formation of the Academy of General Practice in 1947. The forerunner of our state Academy had its first meeting the following year.

While the Baby Boomers were growing up in the 1960s, our specialty was also growing. While society wrestled with the Cold War and the Civil Rights Movement, General Practice was fighting for recognition and respect. As the 60s counterculture movement led Boomers to challenge the values of their parent's generation, General Practice was launching its own counter-culture movement to challenge the medical status quo; along the way coining new terms like Primary Care and Family Practice.

In 1969, the year men first walked on the Moon, the year of Woodstock, and the year Marcus Welby treated his first TV patient, General Practice became Family Practice. Our specialty had come of age with its own certification board, medical school departments, and residency programs.

Like the Baby Boomers, Family Practice thrived in the 70s and 80s. There was much to be proud of. By the early 1980s, Family Practice ranked third of all specialties in the number of residency programs. It had firmly established the concept of primary care as a specialty of breadth, and it had successfully reversed the decline in general practice.

However, the 1990s and the first decade of this century have not been kind to Family Medicine. The promise of managed care—that it would empower and reward primary care physicians—proved to be false. Rather than elevating primary care to its rightful role at the center of the health care system, managed care downgraded family doctors to mere "gatekeepers" in an increasingly dysfunctional system.

Simultaneously, payment reform never materialized, and primary care physicians now struggle with shrinking reimbursement, while operating expenses continue their inexorable rise—a situation that is not sustainable. With these fundamentals, it is little wonder that young physicians are choosing more lucrative subspecialties and avoiding careers—not only in family medicine but also in pediatrics and general internal medicine.

Meanwhile, the American healthcare system is a collection of contradictions. Ours is the most technologically advanced in the world while being unacceptably dangerous. We spend more money per person on healthcare than any other country, yet have mediocre results. Those with the financial means have unlimited access to more tests and procedures than they actually need; while tens of millions go without basic preventive services. Advances in information technology have revolutionized every sector of business, while most physicians are buried beneath an avalanche of paper.

Our specialty and our health care system are in crisis—or, keeping with our Baby Boomer theme, we are having a mid-life crisis. Ironically, this crisis is very similar to the one that gave birth to our specialty so many years ago.

The present may look bleak, but we are in a much better position than our predecessors were 60 years ago. There are several factors that bode well for the future of family medicine and for primary care in general:

The first is the continued progress of science and technology. Information technology and evidence-based medicine now empower any competent physician to become an expert. Medicine is no longer a priesthood with arcane nostrums descending from ivory towers. To paraphrase Archie Cochran, one of the founding fathers of evidence-based medicine, less than 10 percent of what physicians did a generation ago did any good. Today we are beginning to sort out what works from what is worthless.

While some fear a loss of freedom brought about by clinical guidelines, this new focus on quality outcomes actually favors the role of the generalist. Ultimately, the progress of science will not marginalize the generalists. It will empower them. We may always need surgeons and others with highly developed technical skills, but as William Mayo noted, "a specialist is a man who knows more and more about less and less."

The second factor favoring primary care is the inevitability of health care reform. Our present healthcare system is unsustainable. Over the next few years, we will see the intersection of forces that will make reform imperative: An aging population, a shortage of primary care providers, escalating costs; insatiable demand; and a growing segment of the population unable to afford our services. Eventually, these forces will collide. Those with foresight—both in industry and politics—have already come to recognize that primary care medicine must be the foundation of any substantive reform.

And finally, we have something those GPs of sixty years ago did not have. We have this Academy. And we need it more than ever as an advocate and a unified voice for our profession and our patients.

After six decades, our profession once again has the opportunity to affect the kind of healthcare system we will leave to the next generation. Some of the old problems may never be resolved—from the age-old struggle between specialists and generalists to the inequities of reimbursement. These may never change. But also changeless is our commitment to continuous and comprehensive patient care—the foundation of what we do as Family Physicians.

Inaugural address at the SCAFP Annual Assembly.