► About: “Laparoscopic cholecystectomy in a rural family practice”
On the surface, the previous article by Haynes et al1 appears to be a simple descriptive study of a well-established technology. So why publish something that is not new? Simply because the study is an incredible technical and political achievement in a JCAHO-accredited hospital by a family physician educator. All family physicians—whether they view themselves as “procedural” or not—should recognize it for its symbolic and political value.
High-touch and high-tech
If family physicians wish to provide more than “generic primary care,” they must provide clinical skills at the bedside, in addition to diagnostic and psychosocial expertise. No amount of the latter will compensate for the former at critical moments. For credibility in the community and in the life cycle of families, the provision of diagnostic and therapeutic procedures trumps prescription-writing every time.
By providing surgical or diagnostic procedures that improve access to health care in their communities, physicians such as Haynes are not regressing to a surgical mentality at the expense of psychosocial sensitivity and therapeutic listening. Our closest relations with patients and their families are established at the bedside while performing or assisting with a diagnostic or therapeutic procedure. Procedures frequently provide the ultimate “teachable moment.” As said at Keystone III: “You can pretend to know; you can pretend to care; but you can’t pretend to be there.”2
Also, procedures distinguish family physicians from the other “primary care providers” who are hired with the assumption that they will provide referrals. Patients will seek out those physicians who can simultaneously provide high-touch and high-tech.
1960s–1970s: The growth of high-tech
During the 1960s and 1970s, advances in technology were predominantly located in hospitals. The traditional office-based diagnostic and surgical skills of the general physician were gradually transferred to a more central place, namely the hospital. Many of these skills were then categorically assigned to more specialized physicians resulting in the withdrawal of the generalist physician in the participation of these skills.
Originally, family medicine educators thought the 3-year curriculum would be sufficient for procedural training, but they underestimated the political passion for control by opposing specialties with a need to maintain their training monopolies. Among 20 voting specialties, family medicine has only 1 vote. This is the democratic reality, which frames any potential turf struggle in a highly subspecialized environment. These environments include, but are not limited to, academic medical centers, most urban hospitals, and some rural hospitals.
The institutionalization of these interventions depersonalized the patient-doctor relationship, limited access, and escalated cost. Family practice as an emerging specialty willingly joined in this movement, resulting in the abandonment of many generalist-appropriate skills. During that time, studies of how tertiary-care technologies might transfer into the community were undertaken.3,4
It became increasingly evident that many diagnostic and interventional procedures (eg, diagnostic ultrasound, gastrointestinal endoscopy, and colposcopy) had multiple-specialty applications and were clearly linked with important preventive activities. 5,6 Some leaders suggested that technical skills combined with the unique biopsychosocial model of practice of family physicians was the right way to provide competent, personal care to patients. In other words, high-tech was most effective when blended with high-touch and vice-versa. 7-9
1980s–1990s: The FP curriculum expands
In 1981, the first in a series of fourth-year fellowships emphasizing this expanded curriculum for family physicians was initiated.10-12 Thereupon followed the development of CAQ experiences in Geriatric Medicine and Sports Medicine, which, while instructive, failed to create added market value to most rural and under-served communities. The American Academy of Family Physicians—through the Task Force on Obstetrics (1989–1993)13 and then the Task Force on Procedures (1993–1995)—ratified and distributed performance-based learning and competency-based testing programs. Moreover, the Advanced Life Support in Obstetrics (ALSO) program had a major impact nationally and internationally.14
By 1991, our discipline was focused on credentialing for lightning rod issues such as colonoscopy,15 esophagogastroduodenoscopy,16 colposcopy,17 obstetric ultrasound,18 and cesarean section.19 In Memphis, because of the political conflict associated with the teaching of diagnostic ultrasound, gastrointestinal endoscopy, and cesarean section, we chose not to “fan the flames” with development of office-based laparoscopy. But we were ready. We included laparoscopic tubal ligation in our FP/OB fellowship, but the resistance from specialties who felt family medicine was invading “their turf” was difficult and remains so.20-24
By 1995, the Residency Review Committee for Family Medicine had codified the rural training tracks25 and reaffirmed OB-capable faculty as part of the accreditation process. These advanced family practice curriculum needs were acknowledged, and various educational innovations with an emphasis on skills needed for success in rural or urban underserved communities began to emerge.26,27