Belatedly reading the September 2018 issue, I was struck by two articles, clearly related and hopefully published in the same issue for that reason. First is the Eugene C. Rich, MD article “The Physician Workforce and Counting What Counts in Primary Care.”1 The second is a narrative essay by William Hoffman.2
Dr Rich starts by correctly quoting the Millis Commission report on graduate medical education of 1966 which concluded on pages 36 and 37 that there was need for educating and training a new type of physician which they called a “primary physician” not a primary care physician (italics mine).3
Charles Odegaard, PhD, president of the University of Washington and a scholarly historian, was a member of that Commission. I had the great honor to serve on the faculty of the UW School of Medicine starting in 1970 as the founding chair of the Department of Family Medicine. Based on Dr Odegaard’s experience with the Commission, he took a personal interest in what I was doing. Whenever he was in the Health Sciences Building he would stop in my office to catch up with what was happening. A major concern of his was the developing tendency to use the term primary care physician. He would point out that primary care was one of three labels applied to levels or locations in the organization of medical care (primary, secondary, and tertiary); often meaning ambulatory/outpatient, community hospital, and highly specialized hospital. Primary physician instead describes a relationship between patient and physician, which relationship is active at all levels or locations.
The article by Dr Rich correctly attributes to the Millis Commission the name they chose to describe the new type of doctor needed: primary physician. However, in the next paragraph, and throughout the rest of the paper he reverts to the term Dr Odegaard disliked. I have often thought over the years that this confusion is central to many of the conflicts and issues that arise, and so it seems with this article.
In 1980, then President Emeritus Odegaard addressed an audience of family physicians in a continuing education course.4 I have a copy of that address (never published) in which he discussed these issues at length, including other titles they considered: general practitioner, personal physician, first contact physician, family physician, comprehensive care physician; settling finally on primary physician. He also shared a bit of history about what they did next. Believing that the Board of Internal Medicine might be interested in providing certification for this primary physician, they invited influential leaders to a meeting. The conclusion was:
After extended discussion with them, the Commission members became convinced that there was lacking in internal medicine at that time the necessary interest or zeal to lead toward an alternative for a general internal medicine suitable for the primary physician’s role; the drive toward specialization and superspecialism within internal medicine was obviously still very dominant.
The narrative essay by William Hoffman gives substance to the Millis Commission recommendation. Hoffman describes his experience as a medical student on a family medicine rotation in rural Minnesota. The patient described was 88 years old and had multiple strokes. Her family physician doctor had cared for her for 40 years since he first entered practice after residency. Hoffman says “Dr Bob showed me that patients in a well supported rural hospital might have access to something that those in an urban medical center do not.” The student was involved with his mentor in hospital care, hospice care at home, and a final home visit as the patient had chosen dying with her family and friends around her. He concludes with: “Embodying the duality of medicine as both a science and an art, Dr Bob employed evidence-based science while never overlooking the therapeutic value of a simple home visit.”
I am convinced that Dr Bob was the primary physician President Odegaard and the Millis Commission had in mind. He had completed a family medicine residency in 1977, eleven years after the Commission report.