Yesterday’s Patterns, Tomorrow’s Possibilities: Historical Methods in Family Medicine

Many issues in medical education, such as the aims of training, the nature of expertise, and the meaning of professional legitimacy, have long histories. Contemporary scholarship often interprets present concerns through current conditions and responds by proposing new reforms. These approaches are valuable but can overlook how earlier assumptions, debates, and decisions continue to influence what leaders view as problems and which solutions seem plausible today. Even though long-standing narratives often shape contemporary discussions, historical approaches remain underused in medical education research.

Historical research is not a mere glimpse into old news or a nostalgic journey, but a method for explaining how ideas and practices took shape. To generate these insights, historical methodologies emphasize contingency, context, and the consequences of decisions across time. These analytical moves allow researchers to identify patterns of continuity and change that are not easily captured through present-focused methodologies such as literature reviews or program evaluations. By expanding the temporal frame of inquiry, historical analysis broadens the range of explanations and possibilities that education researchers and policymakers might consider when addressing current debates. For example, historical insights can help distinguish between challenges that require new interventions and those that represent recurring concerns shaped by enduring features of medical education.

This manuscript describes a historical analytic approach that we propose is a valuable tool for family medicine researchers. To show how this approach works in practice, we use an example drawn from a study of the Canadian Family Physician (CFP) journal. The example is intended only to illustrate the steps involved in conducting a historical analysis, rather than to present the findings of the study.

The following section offers a four-phase guide for conducting historical research: developing a research question, reviewing what is already known about the historical topic, selecting primary sources and setting feasibility parameters, and interpreting evidence. This approach is not exhaustive, but it reflects a structure common to many approaches in historical scholarship. Table 1 serves as a reference guide to key ideas.

Effective historical inquiry often grows out of a desire to understand the deeper roots of situations that appear familiar today. From this starting point, researchers using historical methodologies develop questions that open pathways into the past.

In 2024, more than 100 family medicine residency openings in Canada remained unfilled, far outpacing vacancies in all other medical disciplines.¹ Just a year earlier, approximately 30% of Canadian medical graduates ranked family medicine as their first-choice speciality, down from nearly 40% in 2016.² Many studies and commentators point to current reasons for this trend and propose possible solutions, including a prominent focus on the structure of training and the culture of medical education itself.^2-12 Educational reform has thus emerged as a leading solution to what is frequently described as a crisis of professional legitimacy, as family medicine continues to seek recognition as a field of equal value within the broader hierarchy of medicine. Few studies, however, have examined how this link between education and legitimacy has developed over time or how family medicine leaders have historically mobilized education as a preferred remedy for the discipline’s recurring challenges in recruitment and reputation.¹³

Although the early decades of family medicine’s development have received limited attention, the period is valuable for understanding how education became central to the discipline’s search for legitimacy. From the late 19th century, general practitioners had grappled with growing perceptions of its inferiority as medical specialization came to define medical progress and prestige. Across North America and Europe, the number of urban general practitioners declined sharply. and notions of a crisis of general practice emerged.¹⁴ By mid-century, with neither its own national professional organizations nor the infrastructure to assess and certify the competent general practitioner akin to those available for specialists, and with dwindling numbers of new trainees choosing to remain general practitioners,^15,16 advocates of general practice began to mobilize (Table 2). By the 1960s and 1970s, these pressures prompted some advocates to reimagine general practice as a new discipline, family medicine, and to turn to educational reform as a strategy for strengthening its status.

This historical era, like any historical period, presents conditions that call for specific research questions to be developed.

For our example study, we asked, (a) How did Canadian family medicine educators and leaders rhetorically position education as the discipline of family medicine was being founded? and (b) To what degree did educational concerns and solutions persist or change over time when the discipline became more established? To address these questions, we conducted a historical analysis of CFP, the journal of the College of Family Physicians of Canada.

Our study adopted an exploratory case study design focused on how questions to employ the interpretive nature of historical research and to avoid analysis that sought to map predetermined outcomes.^17-19 Our case study of CFP drew on historical document analysis, one of several historical methods available, including oral history and material culture analysis.^20-22

Effective historical analysis begins with a review of the historiography. Historiography refers to the collection of historical studies that other scholars have produced on the topic. Examining this work helps identify established findings and areas that need future research. Researchers also review relevant historical scholarship to consider applying guiding concepts or theories²³ (Table 1).

Case Example

In our review of historical literature, we found a paucity of articles or books that explored the professionalization of family medicine in the mid to late 20th century in Canada.^14,24 Many of the histories we found centered on the careers of individual doctors or the conditions of general practice in the 19th and early 20th centuries.^25-28 Significantly, we found no previous study that examined how Canadian family medicine leaders engaged with education as a tool of professional legitimization over the course of the 20th century.

After determining that a research question is not fully addressed in existing historical literature, the next step is to identify primary sources that will anchor the study. Researchers who use historical methods rely on two kinds of evidence. Primary sources come from people who took part in, witnessed, or were directly affected by the period or phenomena under study. These can range widely, from published texts and institutional records to private diaries, letters, photographs, oral testimony, or other material created in the period. Secondary sources, by contrast, are works produced later, often by scholars, who interpret or explain the past. Together, these two forms of evidence give researchers the data they need to construct a historical interpretation.

Because historical interpretation depends on the surviving record, scholars also must consider the practical limits of the evidence available to them. Some materials are intentionally preserved, but far too often, potentially valuable historical documents are dumped into recycling bins or stored in moldy, dank basements. Historical inquiry is thus limited to what traces of the past remain, and researchers can contend only with what has been preserved by choice or happenstance.

After researchers identify their primary source base and set the scope of the project, the next task is to evaluate the sources. In historical work, primary sources serve as the core evidence, but their relevance and reliability must be established before they can support an interpretation.^20,29 This assessment involves determining who created the source, when it was produced, and how directly it speaks to the research question. Researchers also consider why the source was created and how the creator’s perspective may have shaped what was recorded or omitted. Comparing multiple sources helps identify recurring patterns as well as points of disagreement. These steps create a solid evidentiary foundation for the interpretive work that follows.

At the same time, researchers must recognize that no collection of sources can fully capture the complexity of the period under study. Even when records are abundant, they reflect only a portion of experiences, ideas, and debates that once circulated. Some perspectives appear frequently, while others may be fragmentary or absent altogether. Awareness of these limits helps researchers remain realistic about what the available materials can support. By setting clear and responsible boundaries around the scope of the project, researchers ensure that their questions align with the evidence at hand and that their interpretations remain grounded in the historical record.

Case Example

We selected the Canadian Family Physician journal as our primary source base. We chose CFP for four reasons. First, historical document analysis of academic medical journals is accepted as a rigorous and useful method for interpreting prominent priorities and tensions within professional communities and understanding how these concerns continue or change over time.^30-33 Second, as the primary journal for Canadian family medicine clinicians, educators, and leaders, CFP provides an appropriate source base to examine their priorities and concerns. Third was the CFP timeline; CFP began publication in 1967 when family medicine was being established as a new academic and professional discipline.^14,34 Its early volumes capture the formative debates of a field seeking both definition and acceptance. Examining the content of the journal’s first three decades, from 1967 to 2000, allowed us to trace how family medicine leaders positioned education in relation to the discipline’s identity and status. We focused our examination on CFP’s inception in 1967 to the year 2000, the final year for which the digitized issues of the journal were available in PubMed. Fourth, we also chose to examine CFP as a single case study rather than considering multiple journals or national contexts to draw on one author’s familiarity with Canadian family medicine as an academic family physician with many years of education and leadership experience. This focus on a single Canadian family medicine journal also strengthened our ability to attend closely to one specific geographic and political context, rather than dispersing attention across multiple contexts as an international study would require.

We set three feasibility parameters.²⁰ First, we chose to focus our historical examination on family medicine literature that involved family medicine education. Second, to ensure that we were tracking key themes over time, we began with a focused examination of the journal’s first 5 years. This decision allowed us to identify prominent themes present as the discipline of family medicine came into being, knowing that origin stories provide powerful data to evaluate continuity and change. Third, we selected the first 100 returns that the PubMed database determined were most relevant for the search terms “family medicine” and “education” between 1967 and 1972, which based on our dataset offered sufficient information power.³⁵ To connect the beginnings of family medicine education with the decades that followed, we next examined the entirety of the journal’s online database (1967–2000). We reviewed the first 100 returns for the same initial search terms. To assess relevance, we read the titles and abstracts of all 100 items to identify articles that described education. We excluded articles that were descriptions of clinical content, patient/public education, book reviews, and family medicine education beyond Canada. This research project did not require ethics approval because all data were publicly available.

As a case study of one national journal, our research choices will offer only exploratory insights rather than a comprehensive account of family medicine education. The articles in CFP may not fully capture regional diversity or capture all variables.

Historical interpretation asks how a body of sources, read in relation to one another, can explain what people believed, what choices they made, and how particular issues or practices took shape in their historical setting. The emphasis is on understanding the conditions in which people formed their views, the assumptions that shaped their responses, and the social, economic, political, cultural, or scientific factors that framed their decisions. To generate these insights, historical methodologies emphasize contingency over universalism and break down the past into its prevailing conditions and individual choices. Interpretation also involves attention to contingency, which helps to avoid reading the past through present-day expectations or treating historical outcomes as inevitable.^20,21,29 Researchers consider how situations unfolded, noting where ideas or practices changed, where they remained stable, and how intended and unintended consequences shaped later beliefs and actions. By grounding interpretations in context and tracing how people understood and acted within their circumstances, historical methods offer a rigorous and empirical way to explain why ideas or practices took the forms they did.

Although historical methods differ from formal qualitative coding procedures, they share certain inductive features familiar to many social science researchers.^36,37 Scholars may use theories, themes, or sensitizing concepts to orient their reading, yet these remain provisional and open to revision as interpretations evolve through close reading of historical evidence. Historical findings, however, are not typically presented as static thematic lists. Instead, the final product is a narrative account that interprets change and continuity and that explains how ideas or practices were understood, contested, or taken up within a particular setting. Researchers can then situate this interpretation within existing scholarship to clarify how their conclusions align with, extend, or challenge previous arguments.

Case Example

In the middle decades of the 20th century, general practitioners in Canada strove to form a new discipline to counteract prevailing perceptions that general practice was a watered-down version of specialist medicine. As a result, family medicine leaders and educators took on the task in CFP to articulate the distinctive expertise of family medicine and to develop approaches for teaching it. Their discussions addressed the definition of the field, the meanings of training, and the standards around licensing, examination, and certification, all of which were central to establishing family medicine as a professional status.^38-40

In addition to our knowledge of the historical context in which CFP articles were written, we also employed sensitizing concepts of professional consciousness,^41,42 professional project⁴³ and professionalization⁴⁴ to conduct an interpretive reading of our primary source evidence. These concepts helped orient our reading by highlighting how anxieties about the success of professional projects can cause intended and unintended consequences for discourses on education. We focused on content that provided insights on how education is used in the context of professional identity formation, drawing on the understanding that the development of medical student to physician is as much a process of identity formation as the accumulation of skills and knowledge.⁴⁵ We read sources in relation to one another and triangulated our interpretations across multiple CFP articles to position evidence as representative or outlying. We also situated our interpretation of archival data within the literature on the history of medical professionalization, practice, and medical education to understand the broader historical context of our data.^14,24,46-49 This contextual framing helped clarify how authors’ positions reflected the specific professional challenges and opportunities of their time.

Through this iterative interpretive process, we identified curriculum as an important subject of authors’ attention and traced over several decades how authors continued to use discussions of training to negotiate recurring ideas of legitimacy, authority, reform, and crisis. Seen historically, today’s calls for educational renewal are less a new era than a return to familiar efforts to use education to secure legitimacy, attract learners, and sustain public trust.

Our choice of archival data meant that we were able only to examine authors’ written language. We could not verify authors’ intent, for example, in their wording choices or rhetorical positioning, nor ask follow-up questions. To mitigate the potential for misinterpretation, we continually triangulated our interpretation against current historical scholarship, and we contextualized our interpretation with reference to known facts about the authors.

Historical research methodologies are not useful for predictive analysis; nor, with their deep attention to the specificities of time and context, do they facilitate the creation of generalizable principles. In addition, historical research is limited by the traces of the past that remain, leaving the researcher and questions bound only to the sources that endure. These limitations underscore that historical research does not offer exhaustive explanations. It nevertheless offers valuable insights.

As Shakespeare observed, “What’s past is prologue.” All fields of work and research have histories that shape contemporary thought and practice, whether these pasts are consciously attended to or not. For researchers drawn to historical topics, historical methods provide the tools to transform interest into rigorous inquiry. In particular, these methods allow researchers to contextualize contemporary concerns and examine their historical formation.

Historical analysis offers a way to address questions that other methodologies cannot answer, particularly those requiring attention to change over time. Whereas literature reviews and meta-analyzes synthesize existing knowledge, historical approaches offer a different depth of analysis, asking not only what happens in education but why certain responses emerge, change, or endure (Table 3). And while policy or curriculum analyses critique current frameworks, historical work situates them within longer reform trajectories, revealing inherited patterns and assumptions.

In our case example, we used historical methods to discern how earlier leaders and educators understood their circumstances, the options they believed were available, and the consequences their choices produced. As a result, we came to understand how and why family medicine leaders in the latter half of the 20th century championed a new disciplinary identity and advocated for the value of family medicine knowledge and practice. Next, we were able to ask whether family medicine education is caught on a carousel of crisis and reform⁵⁰—a pattern that is difficult to see when analysis is confined to the present. This interpretive lens represents only one of the many possibilities that historical methodologies open to researchers (Table 4).

In this paper, we illustrated one approach to historical work through documentary analysis. Other branches of historical research, including oral history and material culture studies, draw on additional types of evidence and established practices. Regardless of choice of evidence, engaging seriously with history deepens understanding of the present. When attention shifts beyond the limits of the present to the paths that brought family medicine to this moment, the field becomes better able to shape its future with intention rather than habit.

Cynthia Whitehead is the holder of the BMO Financial Group Chair in Health Professions Education Research at University Health Network.