I have grown weary of the pessimism about medical practice that some colleagues are broadcasting today. Continuing to learn about medicine has always been too exciting for me to let other things get in its way. When I think back on family medicine as I have practiced and experienced it, I feel confident that for those who participate wholeheartedly, enjoyment and satisfaction will always follow.
The golden ages
In the beginning, our treatments were limited by the few specific pharmaceutical agents that made a difference: digitalis; aspirin; colchicine; mercurial diuretics; morphine and codeine; and the new specific anti-infective agents, Penicillin, tetracycline, Chloromycetin, and sulfa. Later, it was exciting to be able to treat previously untreatable conditions as more therapeutic agents were discovered. Drugs appeared that reduced blood pressure, and studies finally proved that doing so did make a difference. Antipsychotics and antidepressants emptied the state psychiatric hospitals, and many new antibiotic families were developed. New diseases were discovered: attention deficit disorder, Legionnaire’s Disease, mitral valve prolapse, HIV, carpal tunnel syndrome, to name just a few. This explosion of new knowledge required new specialties which added new people to our medical team. More exacting diagnoses became necessary, and new tools appeared to facilitate our efforts. Disease screening using Pap tests and Hemoccult testing opened a new chapter in early recognition. The introduction of vaccines and the discovery of the relationship between streptococcal disease and acute rheumatic fever, which virtually eliminated mitral valve disorders, heralded disease prevention. What excitement! Surely this was the golden age of medicine—the age of family practice and new therapeutic discoveries.
But wait. I seem to recall that those who first welcomed me into the medical community had also talked about exciting advances; they believed theirs was the golden age of medical practice. They told of giving their first penicillin shot and their excitement in seeing the patient’s rapid improvement. They ushered in the x-ray. My own family doctor had the first EKG instrument, a string galvanometer, in southwest Ohio. They valued the close interpersonal doctor-patient relationships, the diagnostic skills of the physical examination, and the enrichment of listening to their patients. Their golden age excelled in bedside diagnostic expertise and the art of medicine.
And what of those who are now at the peak of their medical careers, those pioneers who dared to enroll in the first family practice residencies, as we struggled to determine the content of that new specialty? Family practice was the first specialty defined by a commission; no precedent existed for practice or training content. The founders of our specialty thrilled to the challenges of describing how family practice differed from general practice and developing its unique body of knowledge based on the process of medical practice. They learned and taught the skills of continuity of care, which make a difference in outcomes. They learned early identification of the nodal points of the natural history of disease at which a change in management could make a difference. They refined strategies of prevention and introduced modification of health risks into practice. Their golden age involves maintaining wellness and managing longitudinal care.
And current family practice residency graduates have their golden age ahead of them. One day these residents will look back on the achievements of their generation: integrating new procedures and drugs, applying evidence-based criteria, remodeling the referral process, incorporating influences from the communities of patients’ work and play, and introducing innovations in patient education.
The good (and the bad) old days
The development of medicine in my lifetime has not been completely unclouded. Medical insurance coverage beginning in the 1950s introduced third-party intrusion to medical practice. Technological advances increased the complexity of medical care and the number of participants in patient care. Initial excitement over the possibilities of prevention has sometimes been lost in the uncertainty of who would benefit from these new measures. However, this kind of uncertainty may create the qualities needed to achieve competency, satisfaction, and excitement in a career in family practice.
Each new generation of physicians should regard its own times as the golden age of medicine. It will share with previous generations an enthusiasm for lifelong learning guided largely by patients. And someday it will look back on its own era in family practice and remember it as the good old days.