 Our second keynote speaker is Joel Howell. Joel is the Victor Vaughan professor of the history of medicine at the University of Michigan in Ann Arbor, where he also holds professorships in the Department of Internal Medicine and Health Services Management and Policy. Joel directs the medical arts program at the University of Michigan. In the past he was the director of the Robert Wood Johnson fellowship program there. He's received the Nicholas Davies Memorial Scholar Award for scholarly activities in the humanities and the history of medicine from the American College of Physicians. Joel attended the University of Chicago Medical School and did his residency training here and completed a PhD in the history and sociology of science under Charles Rosenberg at the University of Pennsylvania. In fact in some regards Joel was the absolute first fellow of the McClean Center because when I went off on sabbatical in 1980-81 to Virginia, Joel took over the ethics program for that year and taught himself. So it was a self-directed fellowship. Joel's research is focused on the history of medical technology and the history of human experimentation. His talk to us today is one which many in the audience have been really looking forward to. It's called The Invention of Primary Care. Join me in welcoming Joel Howell. Thank you very much. I am absolutely delighted to be here and particularly delighted that Mark referred to me as the first fellow. I don't know whether that's actually true or not but I'm proud to have that honor. So I'm going to go historian right now which means A, there will be no slides which based on prior experience means I'm gaining at least two or three extra minutes to talk maybe more. And B as a historian I'm going with the concept of change over time. So the idea that everything that we've talked about today had to be invented, the codes of ethical conduct, normative standards for how we should behave. Those are all inventions of particular people at particular times in particular places and so likewise is the notion of how we divide up how we care for patients. The idea of medical specialties or the lack thereof. So let's start in the 19th century in the United States in a country that in some respects sounds similar and I don't see the gentleman who spoke about India earlier but it sounds similar to what we heard about in terms of being in India today. In that the landscape was wide open, there was very little transportation. It was hard to get from point A to point B and if you got sick and you needed healthcare because of that you were unlikely to go seek out a physician somewhere. You would get care from somebody in your home, probably somebody who could read, could read one of the self-help manuals that were quite common. If you did go see a doctor there was a whole spectrum of doctors you could choose from. You could go to homeopaths, you could go to hydropaths, you could go to osteopaths, you could go to Thomsonians, you could go to botanists, you could go to allopaths. These are all various schools of medicine with different theoretical basis for what makes them legitimate. And this is because we had a true free market in healthcare. I realize I'm here at the University of Chicago talking about free markets but this is what a free market looks like. A free market says anybody can say hi, I'm a doctor and hang out their shingle and practice medicine. That's what it looks like. Another characteristic of medicine at that time is that physicians went to their patients' houses. They stayed there for hours or for days because it was hard to get there. You either walked or rode a horse over some pretty lousy roads often. Physicians, they delivered babies, they took care of children, they took care of adults, they tended to the elderly. They offered ongoing personalized care for all in a sustained partnership with their patients and they practiced inextricably embedded in the family and community context. In other words, they were practicing primary care. But they didn't know they were practicing primary care. They just thought they were taking care of patients. They just thought they were seeing, they were being physicians. So how did things change? Well, as we approach the end of the 19th century and the beginning of the 20th century, we see a number of profound changes, not least being the introduction of technology. And I'm not just talking about medical technology, microscopes and the like. I'm talking about communication technology like telephones. I'm talking about transportation technology like automobiles and paved roads. And we too often are narrow in our conception of what medicine is and how it's practiced. Because if you look, for example, at the Journal of the American Medical Association, they have a special issue on automobiles, what kind of automobile you ought to purchase. Somebody asked a main practitioner in 1920 what was the most important technological innovation in his career and he said paved roads. Another innovation that happened in this time period is the rise of hospitals. Most of the 19th century, most physicians would never have seen a hospital, much less set foot in one. Hospitals were rare examples of care for the poor and the destitute. Hospitals became temples of technology, places where everybody would go for care. There was a revolution in medical education. Medical schools went from two years to three years to four years. Entrance requirements were tightened up. You had to have a high school diploma then you had to have a college diploma. Teaching to hospitals became sites for medical education. It was no longer a free market. States passed medical licensing laws. If you wanted to be a physician you had to be a licensed physician and in this process allopathic medicine became the clear victor. What we now refer to as MDs. Allopaths won. We got the power, we dominated the licensing boards. We defined ourselves as the legitimate purveyors of medical care. And we did so in no small part because we claimed science. Now, I am no Luddite. Technology is wonderful today. I am way too technologized for my own good. I practice medicine and I look at the MRIs and the scans and compare it to when I first met you in the 70s. I mean, my first rounds was looking at tomograms of the cell atersica trying to figure out how big it was. And now what we can do is mind boggling. But we should never lose sight of the fact that although it is incredible what we can do today in 2013, it was just as incredible in 1913. And so the explosion of science on which allopathic medicine based its dominance was no less real then than it is today. Let me give you two examples. One was in 1895, William Rincon. He mails a picture of his wife's hand around the world. He's taken it with an x-ray. He can look inside people's bodies and see the interior and that blew people's minds. So that was exciting. Diabetes. In 1922, some physicians working up in Toronto discovered that they can isolate insulin and treat type 1 diabetes. And children who used to die before their very eyes could now be saved. Was that not phenomenal? Was that not amazing? Was that not something truly, truly mind-blowing? Yes it was. Now, all of this is interesting because you might think that this might have overturned the model of the generalist physician. It did not. It did not. The overwhelming ethos remained unequivocally that of the generalist. It's not that specialization didn't exist. And as we work our way towards the Second World War, we see some specialty boards forming. We see specialty boards in ophthalmology. First one. Why? Because they had a tool. The ophthalmoscope. Radiology. Again, a tool. But ophthalmologists and radiologists weren't likely to offer ongoing continuous care to patients then or now with apologies to the ophthalmologists and radiologists in the room. Internal medicine formed a specialty board in 1936. But we lose sight of the fact that the internal medicine specialty board, and we could talk about other specialty boards as well, had a very different meaning. They didn't think that everybody would be board certified. Board certification in internal medicine was something for the elite physician. It was for the handful of physicians, the very top, and they were not going to see patients on a continuous basis. They were there for the tough cases. If you've got a really hard diagnostic dilemma, you might go to somebody who's board certified. In no sense did they mean that that was the norm for practicing medicine. So what happens? What happens is war. Wars changed medicine, and they changed medicine profoundly in ways that long outlast the conflict. The Second World War starts in 1939. The United States enters the conflict in 1941. And before you know it, the medicine department grows. And at the war's peak, the medicine department of the U.S. Army is three times the size the entire army had been in 1939. So that when you have a big organization, you've got to figure out what are you going to do? How are you going to organize it? They turn to board certification. They said people who are board certified will put them in charge. Makes sense. They had the boards. They could do it. Not only that, but the role of science in the war, obviously in the most prominent role of science was probably things like the atomic bomb and radar. But this is where we had bloodbinding. This is where penicillin came into common use. And physicians left the Second World War with a belief that science and specialization would help them. After the war, they found incredible opportunities to specialize. There were more residency programs. The total residency slots went from 5,700 in 1942 to 25,000 in 1954. Another change that came out of the war was federal support of extramural research. People forget or never knew. This is another example of what's not natural. It's not natural that the federal government should support scientific research outside of its own institutions, even though medical schools like the University of Chicago, like the University of Michigan, like most major universities, depend upon federal research dollars. This was a new invention, a new discovery, and it came explicitly out of the Second World War, and it was divided into specialties. The NIH decided to form study sections, and the endocrinologists met over here, and the rheumatologists met over here, and they awarded funds, and this supported the notion of specialty formation. And the result is familiar. The departments became Balkanized. Internal medicine departments that used to be 10 or 15 people became 200 or 300. They were divided into specialty divisions. Same thing happened in surgery and in all the other departments. Other changes supported the specialization and led to generalists being seen more and more as second-class citizens. Medicare comes along. Medicare was originally announced at the big house at the University of Michigan, my home institution by Lyndon Baines Johnson. Medicare paid specialists more than it did generalists, and so obviously people wanted to go become specialists. And medical care, not Medicare, but medical care, moved into doctors' offices and moved into hospitals. It became uncommon to see a doctor in your home. It became common to go to the hospital. And the general practitioner started to disappear. This disappearance was noted. There were major reports, 1965, 1966, that were presented. One, the Kaga Shaw Report, chaired by Loa Kaga Shaw, former dean of the University of Chicago. And all these reports said we got a problem because the general practitioner is disappearing. And there was epidemiological research, solid scientific research to back up this idea. Kerr-White, some of you know Kerr-White's work, you all should know Kerr-White's work, did pathbreaking work on the ecology of medical care, which showed that although we were spending all of our time and money looking at tertiary and quaternary care in big medical institutions, in fact most sickness takes place outside of big medical institutions, simple diseases in the home. So the general practitioners started to become in a very precarious position. They had lower status, they had lower pay. They were disappearing. Report after report showed they were disappearing. When all else fails, you form a committee and write a report. These days when I have the time I'm going to write a historical study on the impact of reports. It's going to be a depressing study and I'll probably never get funded for anything else after I write it. One solution, if you can't, if the specialty parade is taking over one solution is to join it. So what happens, general practice becomes family medicine. And in 1969 family medicine is approved as the 20th primary specialty board with the American Board of Medical Specialties but family medicine has a problem politically. It's one of either two things. Either it's a new specialty, brand new, with the kind of limited political power you would expect from a new specialty in a world of entrenched older specialties or it's simply a reformulation of general practice in which case they're allowing themselves with a dying field. Neither of those is a position of strength. So what happens then in response is the invention of primary care. It's defining a new entity in explicit contrast to specialized medicine that encompasses parts of older, more established specialties along with the brand new specialty of family medicine. Now it's hard to really say when primary care comes into existence one of these early reports had referred to a primary physician. It first appeared in the New York Times in a letter in January of 1967. We live in a wonderful age. I can say that with authority having searched the New York Times. I mean, in the old days you'd never know because somebody could, you know, it was a hard cup. Anyway, President Richard Nixon who proposed a health care proposal considerably more ambitious than President Obama's which was not, take it up, referred to primary care physicians as the central rationale in 1967 for his new health care strategy. There were structural ideas too that came along to support primary care. The notion of a medical home was first advanced as long ago as 1967 by the American Academy of Pediatrics. The idea that patients should have an accessible, accountable, comprehensive, integrated, patient-centered locus of care has now been widely accepted by a range of specialties and is one of the cornerstones for what we now term primary care. The 70s and 80s saw an explosion of books and articles and reports that said primary care is a good thing and we ought to adapt it. Since then, things have fallen a little bit on hard times. There are primary care residencies that are having a hard time attracting top quality residents. Maybe they're doing it because people are not going to primary care because they want to make more money. The patients they see, maybe they want a more flexible lifestyle. Maybe it's because the medical centers in which they train, present company included, both the University of Chicago and my own home institution and many others, are not particularly wedded to the notion of primary care. Primary care physicians are not generally, and please correct me if I'm wrong, Mark. They're not the ones that are held up as the cream of the crock, the epitome, the uber clinicians. I think that tends to leave people not to spend as much time wanting to go into primary care. The point then, how am I doing for time? I may even get us back on schedule. Who knows? The point then is that primary care had to be invented. It was invented not because somebody did scientific studies that showed that it was the best kind of medical care. It was invented in connection with other kinds of medical care in connection with other kinds of specialties. And Andrew Abbott wrote a wonderful book called A System of Professions, in which he points out that professions exist in relationship one to the other. And you can't study one without studying all of the others. And as one changes, if primary care increases, it will provoke reactions from other specialties. And I think too often historically we tend to look at these things in isolation. How many gastroenterologists do we need? Well, that depends on everybody else. You can't just look at one. Another point is that structural changes are caused by large societal changes. The World War II, I would argue, is the reason we have the specialty dominated system of medicine we have today. We didn't go to war in order to change medical care, but medical care changed because of World War II. We'll go back further. It's a longer story, but the French Revolution brought us the stethoscope, brought us physical diagnosis, brought us clinical pathological correlation. Give me another half an hour and I can explain that. But the point is things change not because we want them to change, they change because of larger societal and structural changes. And we have to take account of that. Another change is technology. I think primary care, I mean specialties came to dominate, primary care is coming back in part because of technology. The telephone was an incredibly important invention for medical care because it meant that you didn't have to drive or get on the back of a horse and go into the doctor's office to make an appointment. We've all got these things in our pockets. Many of you have laptops open in here. It's mind boggling what we can do with this technology to support primary care. It can also be used to take pictures of people and put them on Facebook, as we heard. Or it can be used to support specialty care. How we use the technology is up to us, but it's going to change in ways that are very difficult to predict. So now we've got primary care primarily being delivered by physicians in family medicine, internal medicine, pediatrics, some OBGYN, but not a whole lot. In some parts of the country, osteopathic physicians deliver a significant amount of primary care. And osteopathic medicine is an interesting case study because osteopathic medicine originally was in opposition to allopathic medicine. And now they've come to be very much like allopathic medicine. If you're licensed in osteopathic medicine, you can practice in all 50 states, the military and the District of Columbia. So they claim simultaneously to be fundamentally different and exactly the same. Which is an interesting dance of how long it's going to be sustained. But they're an important part of the primary care delivery system. One hopes, I hope that the Affordable Care Act will lead to many, many more Americans being covered for health care, which will lead to an increased need for primary care physicians. The history of medicine isn't prophecy. I can't tell you what's going to happen. All I can tell you is that things are not going to last forever. Primary care, like internal medicine, like specialty care, these concepts were invented at specific times and specific places by specific people. And they're going to change. The question isn't will primary care be reinvented? Will primary care change? The question is how is it going to change? And the answer to that remains to be seen. Thank you very much. Sure. Thank you so much. That was a wonderful talk. If there are one or two questions, we can take them because Joel has come in under time. That's because I didn't spend five minutes getting my slides set up. Yes, please. Well, there have been a lot of new medical schools, not just Osteopathic. I was trying to count out the number of medical schools in the state of Michigan now, and we were really not sure. They're more and more being created. Exactly. If you're interested, there's actually an article in academic medicine that I published that just came out yesterday looking at the history of physician workforce estimates. And what it shows is that there's an interesting swing back and forth between too many and too few. And a lot of the question, how many do we need depends upon how you define the workforce and who ought to be doing it. I didn't mention non-physician providers, nurse practitioners, physician assistants, lay medical aides, which are going to deliver a lot of that care. I think that the increase in the number of medical schools is great if people wind up going into primary care. I think if it results in more sub-specialists, then it's not going to be so good. One of the historical choices we made, I touched on very lightly, is that we license people as physicians. There were proposals on the table to license people in specialties. So you could have been licensed as a cardiothoracic surgeon. If you didn't have a license as a cardiothoracic surgeon you couldn't practice that. That would have been a way for the state to control the number of cardiothoracic surgeons. Please. Hi, I'm Martin Miguel, University of Illinois. Thank you for letting us visit your campus. I'm wondering how you think the community-oriented primary care community medicine concepts fit in with the future practice of primary care as we move to population health. The primary care physician being responsible for a population, been a medical home or a community and seeking to deal with the social determinants of health. What is your vision for the future primary care practice? I think that's a wonderful idea. If they're given the power to meaningfully change the community and if they're given the political will to do what needs to be done. My fear is that they will not and we will continue to have the same kind of a model. Joel, thank you so much.