Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Marcus Welby and the relentless growth of specialization

Jan Henderson, PhD
Physician
January 31, 2011
Share
Tweet
Share

In the very first episode of the TV series Marcus Welby, MD, our hero delivers an after dinner speech to a group of young interns. As he’s introduced, he hastily scribbles the title of his talk and hands it to the hospital director: “The future of the general practice of medicine, if any.” The year was 1969.

In his introduction, the director somewhat tactlessly remarks that many “eminent specialists” have addressed the group in the past, but tonight they have a general practitioner.

After acknowledging this, Welby continues:

Don’t apologize, You’re right. That’s what everyone thinks. Tell me, doctors, are you a specialist or a GP? Or sometimes they say “or just a GP?” But of course we are specialists. And our specialty, like any other, has certain advantages and certain disadvantages. The money is good, but you have to work three times as hard for it. But you people know all about that.

Since you’re about to choose your specialty, you’ve been amassing information about each. Psychiatry, we know, is practiced sitting down. Dermatologists don’t make house calls.

General practice is performed standing up, sitting down, outdoors, indoors, wherever there’s illness. And that means everywhere. Because, gentlemen, we don’t treat fingers or skin or bones or skulls or lungs. We treat people. Entire human people …

… I hope some of you will go into general practice. For if you don’t, where will a patient turn who doesn’t know that he has an orthopedic problem? Or a neurological problem? Or a psychiatric problem? Or a nutritional problem? But who only knows that, in lay terms, he feels lousy.

I’ve been told I’m a dinosaur, simply unwilling to become extinct. Maybe I am. But perhaps you’ll remember that one of these after dinner chats was given by a moldy old fig, with overtones of megalomania. And that he almost convinced you to go into general practice. You’ll remember it, and you’ll look at your beautiful wife and your two beautiful cars and your beautiful barbeque pit and for maybe three seconds you’ll be sorry you didn’t take his advice. But then, a beautiful breeze off the ocean will restore you to sanity. And you will have missed a hell of a lot.

The relentless growth of specialization

Specialization in Western medicine began in the early 19th century, once the practice of medicine changed from balancing the humors of the body to diagnosing diseases in specific organs. By the late 19th century Americans were traveling to Germany to study the latest clinical discoveries. The US medical market was highly competitive — before the reform of medical education in 1910, anyone could hang out a shingle regardless of qualifications. So offering a specialty – obstetrics, ophthalmology, otolaryngology – as part of a general practice provided an edge.

Specialization grew relentlessly. In 1931, fewer than one out of five doctors was a specialist. By 1969, there were more than three times as many specialists as general practitioners.

Some of this increase was stimulated by forces outside the control of the medical profession. For example, doctors who served in World War II were classified into graded categories. A certified specialist was paid more and given a higher rank than a general practitioner who may have had more experience. The GI Bill (1944) provided four years of subsidized residency training, including a living allowance, increasing the number of specialists. This may have been a well deserved reward for those who had served their country, but it had nothing to do with the health care needs of the 1950s.

The promise of the sixties and seventies

ADVERTISEMENT

Things began to look up for generalists in the 1960s. The term “primary care” was introduced in 1961. Following the creation of Medicare and Medicaid in 1965, the Folsom report recommended not only that every individual should have a personal physician, but that the status and income of those physicians should be comparable to that of specialists. Two American Medical Association reports in 1966 endorsed board certification of primary or family practitioners. In 1969, as Dr. Welby was giving his speech, the American Board of Family Practice was established.

Students who chose family medicine as a specialty in the 1970s were inspired to change the medical culture. The Public Health Service Act of the 1970s, along with private foundations, provided explicit support for training general internists and pediatricians. The Health Maintenance Organization Act (1973) encouraged the rapid growth of HMOs, which tried out the idea of primary care physicians as gatekeepers to specialists. But patients were used to exercising free choice and created a consumer backlash. The subsequent history of primary care has been cyclic and rocky at best.

The future of primary care, if any

Few physicians today seem satisfied with the current state of medical practice in the US, whether they’re classic “specialists” (surgeons), subspecialists (pediatric oncologists), or general specialists (family medicine, general intern, general pediatrician). Our patchwork health care system of competing private enterprises is difficult to control or reform. Primary care physicians in particular complain that there’s too little time to care adequately for patients, too much bureaucratic paperwork, and – just as in Welby’s time – lower incomes.

If one of today’s young and idealistic doctors gave an after dinner speech on “The future of primary care, if any,” she could still find some grounds for optimism, however. It might go like this:

Our current health care system was created at a time when most patients suffered from acute, often infectious conditions that needed immediate attention. That is no longer true today. The majority of our patients have modern “lifestyle” conditions: diabetes, obesity, coronary artery disease, lung cancer, strokes, chronic degenerative diseases.

In the past, it made sense to organize health care into subspecialties that would treat acute, current conditions. But the health of our patients has changed. By the time a patient needs an oncologist, a cardiologist, an endocrinologist, or a surgeon — in many of those cases it would be fair to say that medicine has failed that patient.

What we need today is to recognize the crucial importance of integrated primary care systems, as well as public health policies that acknowledge and address the social determinants of health. We must provide financial incentives that attract and reward high quality primary care practitioners – and give them the time they need to care for their patients. Our goal could then be to empower our patients and give them hope that they may never need to see a specialist.

Jan Henderson is a historian of medicine who blogs at The Health Culture.

Submit a guest post and be heard on social media’s leading physician voice.

Prev

Focus advance care planning on outcomes

January 31, 2011 Kevin 0
…
Next

Physician blogs, doctors on Twitter and a malpractice trial

January 31, 2011 Kevin 19
…

Tagged as: Primary Care, Public Health & Policy, Specialist

Post navigation

< Previous Post
Focus advance care planning on outcomes
Next Post >
Physician blogs, doctors on Twitter and a malpractice trial

ADVERTISEMENT

More by Jan Henderson, PhD

  • a desk with keyboard and ipad with the kevinmd logo

    Is medicine a science?

    Jan Henderson, PhD
  • a desk with keyboard and ipad with the kevinmd logo

    For doctors who suffer from burnout, the ultimate tragedy is suicide

    Jan Henderson, PhD
  • a desk with keyboard and ipad with the kevinmd logo

    Doctors are asking whether the physical exam is becoming a lost art

    Jan Henderson, PhD

More in Physician

  • Why judgment is hurting doctors—and how mindfulness can heal

    Jessie Mahoney, MD
  • Why evidence-based management may be an effective strategy for stronger health care leadership and equity

    Olumuyiwa Bamgbade, MD
  • The gift we keep giving: How medicine demands everything—even our holidays

    Tomi Mitchell, MD
  • From burnout to balance: a neurosurgeon’s bold career redesign

    Jessie Mahoney, MD
  • Why working in Hawai’i health care isn’t all paradise

    Clayton Foster, MD
  • How New Mexico became a malpractice lawsuit hotspot

    Patrick Hudson, MD
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How veteran health care is being transformed by tech and teamwork

      Deborah Lafer Scher | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Recent Posts

    • How veteran health care is being transformed by tech and teamwork

      Deborah Lafer Scher | Conditions
    • Why judgment is hurting doctors—and how mindfulness can heal

      Jessie Mahoney, MD | Physician
    • Why medical schools must ditch lectures and embrace active learning

      Arlen Meyers, MD, MBA | Education
    • Why helping people means more than getting an MD

      Vaishali Jha | Education
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • Why evidence-based management may be an effective strategy for stronger health care leadership and equity

      Olumuyiwa Bamgbade, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 32 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How veteran health care is being transformed by tech and teamwork

      Deborah Lafer Scher | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Recent Posts

    • How veteran health care is being transformed by tech and teamwork

      Deborah Lafer Scher | Conditions
    • Why judgment is hurting doctors—and how mindfulness can heal

      Jessie Mahoney, MD | Physician
    • Why medical schools must ditch lectures and embrace active learning

      Arlen Meyers, MD, MBA | Education
    • Why helping people means more than getting an MD

      Vaishali Jha | Education
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • Why evidence-based management may be an effective strategy for stronger health care leadership and equity

      Olumuyiwa Bamgbade, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Marcus Welby and the relentless growth of specialization
32 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...