Champions of Generalism

In June 2020, the Accreditation Council for Graduate Medical Education (ACGME) approved complex family planning (CFP) as a new subspecialty of obstetrics and gynecology (Ob/Gyn). Training in CFP requires a 2-year fellowship after the completion of a 4-year Ob/Gyn residency.1 The application requesting recognition of new subspecialty states that unaccredited fellowships in CFP have existed since 1991 and defines the purpose of the new field as improving research into contraceptive technology and pregnancy termination.2 It further distinguishes between CFP and the existing subspecialty of reproductive endocrinology and infertility (REI), explaining that REI has “become focused on assisted reproductive technologies such as in vitro fertilization.” In essence, REI is about helping women to become pregnant and CFP is about helping them to prevent it. It is likely that this is news to many of our readers; in this issue, Shih and colleagues report that only 8% of family medicine department chairs were aware that this was being considered when surveyed in the fall of 2019.3

Apparently, there were few objections from family medicine organizations during the ACGME’s required public comment period. The number of CFP fellowships is likely to remain small, and newly minted subspecialists in this field are unlikely to impact most American communities. The application for approval of the field stated that only 26 fellowship positions existed in 27 programs in the entire country in 2018.2 An increased focus on contraceptive research might be beneficial at a time when maternal-child mortality is increasing in our country. In addition, research into pregnancy termination might make abortion services safer and more available to women in America, outcomes considered desirable by many. Shih and colleagues suggest that the new field could lead to restrictions on the scope of practice for family physicians, but the numbers suggest this is unlikely. So, one might reasonably question why this would matter to family physicians or family medicine educators.

One reason to care about this is that it so clearly demonstrates how narrowly focused medical education has become. The ACGME-approved program requirements for CFP fellowships mandate that fellows understand “anatomy, reproductive physiology and endocrinology, and pathophysiology as they relate to contraception, pregnancy location, and uterine evacuation.”1 But there is no requirement for training in mental health assessment, family systems, or counseling for couples. Fellows should “complete a two-week block rotation in a low-resource family planning setting,”1 but there is no requirement for assessing social determinants of health in such communities. Ob/Gyn has always focused on just one organ system. Now even that limitation does not seem narrow enough.

The point of all this is not to criticize our Ob/Gyn colleagues because overspecialization is endemic in American medicine, and our own specialty is not immune. For over 5 decades, our medical education system has trained individual physicians to provide increasingly narrow services and we have now reached a point where a dwindling number of us can actually provide generalized care even within our own specialty fields. Will a newly minted subspecialist in CFP still deliver babies and share call with general obstetrician-gynecologists? Experience with other disciplines suggests that they will not. Thus, creating this new field will not obviate the shortage of physicians providing maternity care to underserved populations where maternal child health disparities are the most severe. Maternity care is essential for community health, but fewer family physicians and fewer obstetricians are providing this service in practice, and American communities are feeling the impact. The increase in maternal-child mortality is not due to insufficient contraceptive research. It is increasing because there are more people living in poverty and because basic services have become less available, even as the total number of physicians increases.4

Generalism has been in decline in American medicine for a generation, even though our specialty was created to restore it. First a problem in surgery and internal medicine, the trend now infests every medical specialty. Within family medicine, we originally envisioned that those with certificates of added qualification in sports medicine and geriatrics would maintain a comprehensive practice including all of family medicine. Has this turned out to be the case? And now we debate whether rural practice should be a fellowship because we can no longer reliably train every residency graduate to competently practice in communities where broad generalist skills are essential. In his famous paper “Family Medicine as Counterculture,” Gayle Stephens wrote:

My hope is that we can find leaders who are willing to rethink the priorities of medical education on the basis of the medical needs of the public rather than on the basis of preserving the professional self-interest of organized medicine. We have told ourselves and the public that we are committed to excellence in medicine. I hope we can take an honest look at what that really means. Surely it means more than technical competence and, at the very least, it means providing enough physicians who are willing to serve all people for the majority of their medical needs in settings that are as close to the people as possible.5

The approval of a new subspecialty in CFP is, in itself, not a big deal. But every physician who abandons the general practice of their specialty is a physician who moves farther from the demands of community service. To be worth the investment of time and money, more training should prepare people to do more, not less. Why in the world should it take 6 years of postgraduate training to produce a physician to provide complex family planning? If the ACGME really thinks this is necessary, how can we reasonably argue that a family physician can learn to deliver comprehensive care to all family members in just 3 years? The founders of our discipline hoped that family physicians would be champions of generalism in our profession. They dreamed we would restore sanity to American medicine and not simply take up residence in the asylum with the other specialties. Teaching physicians to care for fewer and fewer problems is silly when it comes to population health. It is our job to say so, and to manage our own specialty accordingly.