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10 Mileposts on the Long Road to Primary Care

10 Mileposts on the Long Road to Primary Care

  • We've come a long way: The Origins of Primary Care

  • 1. A More Enlightened Approach to Medicine: The Enlightenment saw the ascendance of the natural sciences as knowledge of chemistry replaced the theory that all things are made up of earth, air, fire, and water. William Harvey’s discovery of the circulation of the blood was a landmark of medical progress as was his new experimental method. Despite attempts to discover simple ways to heal the sick, Hippocrates’ system of straightforward clinical observation was widely adopted.

  • 2. Born in the USA: Medical practice in early 17th century England was divided into physicians, surgeons, and apothecaries, but the distinction did not last in colonial America. MDs who practiced in the colonies also performed surgery and prepared medicines. The first organization of medical professionals, the New Jersey Medical Society, was founded in 1766. By the early 1800s, medical societies were in charge of establishing regulations, standards of practice, and certification of doctors.

  • 3. A Rush to Higher Learning: The University of Pennsylvania established the first US medical school in Philadelphia in 1765, bringing key new elements into medical education: a med school within an institution of higher learning and lectures supplemented with bedside teaching. Controversial physician Benjamin Rush, a signer of the Declaration of Independence, taught Chemistry and Theory and Practice of Medicine. He started two colleges, moved medicine toward more comprehensible and manageable diagnoses and treatment regimens, and became known as the “father of American psychiatry.”

  • 4. Early House Calls: Health care was still somewhat unstructured in small-town America in the early 1800s. Doctors often visited patients via horse and buggy and took care of all family members, providing a wide range of services. Although most doctors did not have formal training, many were astute clinicians, with great knowledge, capabilities, and commitment. But there were no standards of care and “quackery” was prevalent.

  • 5. The AMA Organized Medicine: The American Medical Association was founded in 1847. Standards for preliminary medical education and for the degree of MD were established, and the AMA Code of Medical Ethics was written and published. The AMA recommended “that the value of anesthetic agents in medicine, surgery, and obstetrics be determined”; noted “the dangers of universal traffic in secret remedies and patent medicine”; and established “a board to analyze quack remedies and nostrums and to enlighten the public in regard to the nature and danger of such remedies.”

  • 6. Pasteur Gave Medicine a Shot in the Arm: The French chemist was the father of germ theory, which became central to understanding of disease. He also found that many micro-organisms in liquids such as milk could be killed by heating the liquid—“pasteurization”—and showed that the decay of meat was caused by microbes. Pasteur went on to develop the first laboratory-developed vaccine, for chicken cholera; an anthrax vaccine; and the first rabies vaccine.

  • 7. Art and Science Out of Whack: In 1910, the Flexner Report urged medical schools to enact higher admission standards and to embrace scientific knowledge in teaching and research as European schools did. “Proprietary” medical schools were eliminated, and the biomedical model became the gold standard of medical training. “Excellence in science…was not balanced by a comparable excellence in clinical caring,” but subsequent revisions “are re-claiming the rightful eminence of the service component of medicine―the centerpiece of the doctor-patient relationship.”

  • 8. All in the Medical Family: In 1969, the American Board of Family Practice was officially recognized as the 20th primary medical specialty. Even though the number of physicians in general practice was dwindling, the medical establishment was opposed. The board created a new generalist specialty, “Family Practice,” that would have graduate programs for physicians to include training in first-contact, continuous, comprehensive, personal, and family care and competency in scientific general medicine.

  • 9. Managed Care Brought Adverse Effects: In the late 1980’s, managed care was designed to provide coordinated health care and control costs, but the negative side effects were many. Gatekeeping arrangements that required patients to select a PCP or obtain authorization for specialty referrals were associated with lower ratings of the patient-PCP relationship. Uninsured adults rated their relationships as significantly poorer than insured patients. Perceived choice of PCPs, but not access to or continuity with PCPs, attenuated some of the negative effects.

  • 10. Modern Medical Advances for $1000, Alex: Some milestone medical advances in the 20th and 21st centuries:
    1922: Insulin first used to treat diabetes.
    1923-1927: First vaccines developed for diphtheria, whooping cough, tuberculosis, and tetanus.
    1928: Penicillin discovered by Sir Alexander Fleming
    1952: First polio vaccine developed by Jonas Salk
    1987: First statin approved by FDA
    2006: First vaccine to target a cause of cancer

How is your recall of the highlights of the past 4 centuries in medicine? What were the high points along the path to modern primary care practice? To help fill in any blanks, we trace the history of modern medicine, from the Enlightenment to managed care, in the 10 slides above.

For deeper background still, see a previous slideshow, 10 Milestones in Early Medicine, which illustrates some of the more significant developments in the long history of medicine, from ancient times through the Renaissance.



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