What Family Medicine Was Built For

Family medicine was invented in 1969 to solve a specific problem. The problem is worse now than it was then.

The crisis was clear to anyone paying attention in 1965. American medicine had become increasingly specialized. Subspecialists were proliferating. The general practitioner tradition was dying — the last generation of GP-only medical school graduates was entering practice. And patients were the casualties. A patient might see a cardiologist for heart disease, a nephrologist for kidney disease, an endocrinologist for diabetes. Each specialist knew their domain. Nobody integrated the care. The patient's whole story was lost in the fragments.

Two major commissions reported on the crisis in 1966. The Willard Report, formally *Meeting the Challenge of Family Practice*, was commissioned by the American Medical Association. The Millis Commission Report, formally *The Graduate Education of Physicians*, was a citizens commission on medical education. Both identified the same problem: fragmentation of American primary care. Both recommended the same solution: create a specialty of family medicine with dedicated residency training.

The arguments in these reports are worth recovering, because they named something that remains true today. The problem was not that specialties existed. The problem was that no one clinician was responsible for the whole patient. No one clinician knew the patient over time. No one clinician could integrate care across specialties or coordinate treatment. The system had no integrator. The patient was parceled out.

Family medicine was designed to be that integrator. The specialty was founded on the principle of continuity of care — one clinician, knowing the patient over years, able to manage most conditions and to coordinate specialty care when needed. The founding vision included full-spectrum practice as the default: obstetrics, pediatrics, adult medicine, behavioral health, minor procedures. The family physician was the physician for the full life course, the physician for the complicated patient, the physician for the patient without clear pathology who was nonetheless suffering.

The first family medicine residencies opened in 1969. By 1971, the American Board of Family Practice (now the American Board of Family Medicine) had been established. By the end of the 1970s, hundreds of residencies existed. The specialty grew rapidly. It offered something medicine needed: a designation for the clinician who was supposed to think about the whole patient.

But the founding vision did not survive intact.

Two things happened. First, payment structures changed. Family medicine income dropped relative to other specialties. Specialists billed higher. Procedures billed higher than evaluation and management. The economic incentive structure rewarded specialization, not integration. A family physician could make substantially more money by focusing on procedures (minor surgery, joint injections, minor orthopedics) than by managing the complex medical problem that did not fit clearly into any specialty. The payment structure systematically pulled family medicine toward narrowness.

Second, training structures changed. Residency programs became increasingly urban and academic. Rural programs persisted and maintained more of the full-spectrum vision. Community health center programs often maintained the full-spectrum vision. But in urban academic medical centers, specialization became the default. Obstetrical training in family medicine programs became optional. Inpatient training contracted. Procedures declined. The program might say it trained full-spectrum family physicians, but the program's structure did not actually require them.

The result is that family medicine, as it exists in many urban academic settings today, is narrower than the specialty was designed to be. It is good medicine, often excellent medicine. But it is not the medicine the specialty was founded to practice.

What was the founding argument?

The Willard Report stated that the core content of family practice included "management of patients with acute illness, chronic disease, and preventive health services." But more importantly, it emphasized the longitudinal relationship. The family physician was supposed to know the patient's family history, social situation, prior illnesses, and patterns of health over time. That knowledge was not incidental — it was central to the family physician's clinical reasoning. The Millis Commission emphasized integration across the specialties: the family physician was the "personal physician" for the patient, responsible for ensuring coordination of care even when the patient saw multiple specialists.

Both reports emphasized that family medicine would practice in settings where full-spectrum practice was necessary: rural areas, small towns, community health centers. These were not marginal settings. These were where most Americans would live and receive care. The specialty was not founded to staff urban academic medical centers. It was founded to be the medicine that took care of whole populations.

Ian McWhinney, the Canadian physician-philosopher who became family medicine's intellectual anchor, wrote that the discipline of general practice (his term) was defined not by a specific set of conditions but by a commitment to being the first-contact physician, the physician who would see anyone with anything and would be responsible for the ongoing care of that patient over time. The specialty's scope was defined by population and relationship, not by pathology.

What happened to this vision?

In urban academic medicine, it fractured. Family medicine became increasingly competitive with internal medicine for the ambulatory patient with routine problems. The full-spectrum practice (obstetrics, pediatrics, behavioral health, minor procedures) required different training and expertise than managing the complicated patient with multiple chronic diseases. Residency programs had to choose. Most chose to emphasize chronic disease management and outpatient medicine, because those are what urban academic practices could support. Obstetrics was time-intensive and required maintaining skills. Inpatient medicine was labor-intensive. The programs retreated to what they could easily do.

In rural and community settings, the full-spectrum vision persisted. Rural family physicians still do obstetrics. Community health center family physicians still manage the full range. The FQHC family physician is often the only option for birth control, STI testing, prenatal care, pediatrics, adult medicine, and behavioral health. The full-spectrum vision persists where it is structurally necessary.

The specialty was supposed to be founded on payment reform and training structures that would support full-spectrum practice in all settings. That reform never happened. The payment structure continues to reward specialization. The training structure continues to be pulled toward specialty-like narrowness in academic settings. The consequence is a specialty divided between the full-spectrum vision (in rural and community settings where it is structurally necessary) and a narrower chronified-disease-management model (in urban academic medicine where that is what the system can support).

This is not a failure of family physicians. It is a failure of the country to build the specialty out to the full deployment its founders imagined.

What would have to change to recover the founding vision?

First, payment reform. Fee-for-service payment that rewards procedures and specialists cannot support full-spectrum family medicine. A physician who does obstetrics, pediatrics, and adult medicine cannot bill the same volume as a specialist who does only one thing. Capitated payment, payment per patient per month, could align incentives with full-spectrum care. But capitation requires population health commitment and investment in primary care infrastructure. It is not what the current market provides.

Second, training reform. Residency programs would have to require full-spectrum training. Every family medicine graduate would have to complete obstetrical training. Every graduate would have to have pediatric experience. Every graduate would have to maintain continuity across a full patient population — pediatric, pregnant, adult, elderly. This is possible; it is what some programs do. But it is not the default in urban academic programs.

Third, workforce deployment reform. Family medicine would have to be deployed to the sites where it is designed to work: rural areas, small cities, community health centers. This requires not just training but also support. Loan repayment programs. Payment incentives for working in underserved areas. Workforce planning that explicitly directs family physicians to the sites where their skills are most needed.

The Limited-Resource Medicine essay (Issue 010) argued that the medicine the Liverpool diploma trains for is the actual practice of medicine for tens of millions of Americans — Pine Ridge, the Mississippi Delta, Appalachia, the FQHCs and tribal sites. Family medicine was designed to be that medicine. The specialty was founded to solve the problem of integration and continuity in exactly these settings.

What the founding documents argued is that the patient without a personal physician is a patient at risk. The patient seeing multiple specialists without coordination is at risk for fragmented, conflicting, and sometimes harmful care. The patient in a setting without nearby specialists needs a clinician trained in full-spectrum practice. These arguments remain true. The conditions they describe have not improved.

The specialty of family medicine persists. It attracts physicians who want to practice generalist medicine. Programs exist that still train full-spectrum family physicians. Rural practice persists. But the vision of a systematic deployment of family physicians to the sites where they are needed, trained broadly enough to manage the full range of conditions they will encounter, compensated fairly for their work — that vision has not been realized.

Recovering the founding argument is not a matter of retrieving an idealized past. It is a matter of asking: what was the specialty designed to do, and is that still what the country needs? The answer to the second question is yes. The problem the founding documents identified — fragmentation, lack of integration, patients without personal physicians — has worsened. More specialties exist. More patients see multiple specialists without coordination. The rural and community settings where full-spectrum practice is essential are more undersourced than ever.

What would have to happen for family medicine to become what it was built to be? The answer is: investment. Payment reform. Workforce planning. Support for training programs that maintain the full-spectrum vision. Deployment of physicians to the sites where the specialty's skills are most needed.

The specialty was designed for what the specialty is doing at its best. The gap between the founding vision and current urban academic practice is not a failure of family medicine. It is a failure of the country to build the specialty out to the full vision its founders articulated.

That vision remains worth recovering. The patient who needs a personal physician, continuity of care, integration across specialties — that patient is still there. The places where full-spectrum practice is essential — rural areas, FQHCs, tribal health centers — still need it. The specialty exists. What remains is the work of deploying it to where it is needed and structuring practice and payment to support what it was designed to do.

**The 1966 context.**

To understand what family medicine was founded to do, you have to understand the medical landscape in 1965. American medicine had been consolidating into specialties for decades. The general practitioner — a physician with no specialized training — was the default primary care provider. But GP training was variable. Some GPs had excellent practices. Some were poorly trained. The line between what a GP could competently manage and what required specialist care was blurry.

At the same time, medicine was increasingly capable of treating specific diseases. The development of antibiotics meant that infections could be treated. The development of insulin meant that diabetes could be managed. Cardiac care was becoming more specialized. Orthopedic surgery was becoming more specialized. The medical system was splitting into specialists who knew a lot about one thing and generalists who knew a little about many things.

The problem was that patients did not come with one problem. A patient might have diabetes, hypertension, heart disease, arthritis, and anxiety — all at once. The specialist in cardiology knew about heart disease. The endocrinologist knew about diabetes. But nobody knew the whole patient. Nobody was responsible for integrating the care. The patient was pieces, scattered across specialists.

The Willard Report and Millis Commission Report identified this as a crisis. The country needed physicians who could be the integrator. Who could know the patient over time. Who could manage multiple chronic diseases. Who could decide when to refer to a specialist and when to manage in primary care. Who could prevent inappropriate specialist care and coordinate specialist care when needed.

This was not a rural crisis or an urban crisis. It was a system crisis. Every patient without a personal physician was at risk. Every patient navigating multiple specialists without an integrator was at risk for fragmented, conflicting care.

**The residency structure that would support full-spectrum practice.**

If family medicine was designed to do full-spectrum practice, then the residency training had to support it. The founding vision included obstetrics as a core requirement. Family medicine residents were expected to deliver babies. To manage prenatal care. To manage deliveries, including complications that were emergent but not requiring operative delivery.

Why obstetrics? Because pregnancy and delivery are what happen to women in full-spectrum practice. If a family physician is going to be the personal physician for a woman throughout her reproductive life, the family physician needs to be able to manage pregnancy, delivery, and postpartum care. Referring every pregnancy to an obstetrician fragments care.

The residency also included pediatrics as a core requirement. Family physicians were expected to manage the full range of pediatric conditions. Respiratory infections, ear infections, developmental problems, behavioral issues, vaccinations. Again, if the family physician is the personal physician, the family physician needs to be able to manage children.

The residency included inpatient medicine. Family physicians were expected to have admitting privileges and to care for their own patients in the hospital. This is where continuity of care really matters. The physician who knows the patient over time can explain nuances about the patient that are not in the chart. Can make decisions about goals of care based on the patient's prior wishes.

The residency included procedures. Not major surgery. But the procedures that come up in primary care. Laceration repair. Joint injections. Abscess drainage. Minor skin procedures. The family physician needed to be able to handle the minor problems that would otherwise require a referral.

This is a lot for three years of training. It is a lot for three years of training combined with additional fellowship training. It is certainly more than can be fitted into a three-year residency in an urban academic setting where the program is competing for time with numerous other rotations and where each rotation is expecting to teach residents to be expert in that specific area.

**What happened to the vision in urban academic programs.**

In many urban academic medical centers, the full-spectrum vision contracted. The obstetrical training became optional. Residents who did not want to deliver babies could opt out. The residency program could still claim to train family physicians, but it was training family physicians who did not do obstetrics.

The inpatient training contracted. Residents got less time on inpatient medicine. Some programs no longer had family medicine inpatient services. Residents admitted their patients but did not follow them consistently.

The procedural training contracted. Residents got less practice with minor procedures. Some procedures were done exclusively by specialists.

The reasoning was pragmatic. The program is in an urban setting. Most family physicians in urban settings do not do obstetrics or inpatient medicine. Why train residents for a practice model they are unlikely to use?

The answer that the founding documents would offer is: because that is what family medicine is. The specialty is defined not by what is convenient to teach in urban academic settings, but by what serves patients best.

**The economic problem.**

The core problem is payment. Fee-for-service payment rewards volume and procedures. A specialist who does procedures can bill for each procedure. A family physician who manages chronic disease bilIs for office visits, which are low-value compared to procedures. The economic incentive pulls toward specialization.

This is not a problem that can be solved by training alone. You can train residents to do full-spectrum family medicine, but if the payment structure makes it impossible to sustain a full-spectrum practice, the training was wasted.

What would support full-spectrum family medicine financially? Capitated payment. Payment per patient per month, with incentives for managing the patient's total health. Preventive care bonuses. Quality bonuses. Payment models that reward continuity and integration, not volume and procedures.

These payment models exist in some settings. Health maintenance organizations use capitation. Some integrated health systems use capitation. Some community health centers use capitated models. But fee-for-service remains dominant in American medicine. And fee-for-service pulls toward specialization.

**Where the full-spectrum vision persists.**

In rural areas, family physicians still do full-spectrum practice because there is no alternative. The rural family physician still delivers babies because there is no obstetrician in the county. Still manages pediatrics because there is no pediatrician. Still does inpatient care because the small hospital needs family physicians on staff.

In community health centers and FQHCs, family physicians still do full-spectrum practice because the patient population needs it. These are the settings where the founding vision is still deployed as designed.

In tribal health centers, family physicians do full-spectrum practice because the tribal clinic is often the only medical resource for miles. The family physician is not choosing to do full-spectrum medicine; it is imposed by the structure.

These settings have something in common: they are undersourced. They do not have the luxury of specialists. They do not have the luxury of fragmenting care across multiple providers. The family physician has to be everything because everything is needed and nothing else is available.

The founding documents would recognize this. The specialty was created to serve these settings. The specialty is doing what it was designed to do in rural practice, in FQHCs, in tribal health centers. The success of the specialty in these settings is evidence that the founding vision was right.

**What it would take to scale the vision.**

To deploy family medicine to all the settings where it is needed would require: (1) payment reform to support full-spectrum practice; (2) residency reform to require full-spectrum training; (3) workforce planning to direct family physicians to underserved areas; and (4) support structures to make rural and community practice viable.

Payment reform means moving away from fee-for-service toward payment models that reward integration and continuity. This would benefit all of primary care, not just family medicine. It would allow internists and pediatricians to also practice in more integrated ways.

Residency reform means requiring full-spectrum training, at least at the level of recognizing the scope of family medicine. Residents should know how to manage pregnancies, deliver uncomplicated deliveries, manage pediatrics, admit patients to the hospital. They do not need to be expert in all of these — some may choose to focus on specific areas in practice. But they need to know what the work entails and why it matters.

Workforce planning means recognizing that certain areas need full-spectrum family physicians and creating incentives to attract them. Loan repayment. Housing support. Flexible schedules. Meaningful work. The rural family physician and the FQHC family physician are doing essential work that no other specialty is positioned to do.

Support structures means ensuring that rural hospitals can sustain family physician-led inpatient care, that FQHCs can sustain prenatal and delivery services managed by family physicians, that tribal health centers have resources for comprehensive care.

**The moral argument.**

There is a resource argument for full-spectrum family medicine: it is more efficient to have one physician know the patient and manage most problems than to have the patient see multiple specialists.

There is a payment argument: capitated payment can make full-spectrum practice financially viable.

There is a clinical argument: continuity of care improves outcomes and improves patient satisfaction.

But there is also a moral argument: the patient who needs a personal physician should have one. The patient in a small town or a rural area or a community health center should not be told "there is no specialist, so we cannot help you." The patient should have a physician who can do what is needed, and who can coordinate with specialists when needed.

The founding documents of family medicine made this argument: every patient deserves a personal physician. Every patient deserves continuity of care. Every patient deserves to have someone who knows them and is responsible for the whole picture. Family medicine was designed to fulfill that commitment.

Fifty years later, the commitment remains unfulfilled. There are patients without personal physicians. There are patients whose care is fragmented across multiple specialists. There are places without specialists but also without adequately trained family physicians.

The specialty exists. The training pathways exist. What remains is the work of deploying the specialty to where it is needed, structuring practice and payment to support it, and committing the resources required to make the founding vision real.

The specialty was built for what the specialty is doing at its best. The gap between founding vision and current reality is not a failure of family medicine. It is a failure of the country to build the specialty out to full deployment. That work remains to be done.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.