Lecture February 10, 1989
18/18
Address by C. Everett Koop, MD, ScD
Surgeon General of the U.S. Public Health Service
U.S. Department of Health and Human Services
Presented to the University of New Mexico Medical Center
Albuquerque, New Mexico
February 10, 1989
This is one of two lectures that I gave in Albuquerque on February 10,1989. One was presented to the Greater Albuquerque Medical Association and had to do with the current issues in AIDS and that lecture, complete with front sheet and comment, is presented elsewhere in this archive. This was an address presented to the University of New Mexico Medical Center in Albuquerque, and it was to the faculty, some ancillary staff, and almost all the medical students.
The presence of medical students requires some explanation. The first lecture I had been asked to give was the one on AIDS to the Medical Society and this was a secondary invitation that came after the Medical School knew that I would be in town for the AIDS lecture. What I did not know was that as far as the medical students were concerned, their mid-winter vacation began at 12 o'clock noon and anybody that came to hear what I had to say had given up the most emotionally satisfying part of any vacation-the first hour after it begins. I appreciated that show of interest and warmth of that audience in a special way.
The reason for including this lecture is primarily because of one of the questions that was asked me by a student after the lecture was over and led to a discussion of something that does not appear elsewhere in this archive, under speeches I gave as the Surgeon General. The lecture itself is a great history of medicine and a look into my crystal ball about things that might happen in the next decade. It's worth reading. But let me get to the subject of the question.
Several years after this lecture was given the subject of the question I wanted to discuss was commonplace. Indeed in my life in the private sector as a lecturer, I talked about this subject many, many times. But it had not yet reached sufficient critical importance to be part of medical school or lay discussions
The question from one student was this: " I have a problem Sir, for which I need some advice." My grandfather and my father have practiced family medicine in rural New Mexico for the past two generations. I went to medical school with the general thought of following in my ancestor's footsteps and doing the same thing. Yet, when a faculty member here asked me what I planned to do with my life after graduation, and I said I'm going into primary care or I'm going into family practice with my father. I was subjected to humiliation ands a tirade in front of classmates and other faculty about my stupidity in wasting a great medical education by going into primary care or family practice. It has gotten to the point where I would rather not tell anyone what I plan to do to avoid the consequences. Am I really off-base in thinking that I should follow my grandfather and father in the practice of family medicine?"
At the time that this young man asked the question, 28% of physicians in America were in primary care and that included general practice, pediatrics, a small segment of those who called themselves internists, and a handful of obstetricians and gynecologists. That meant that 72% of American doctors were specialist. There never has been a study to show what the proper partition of specialists versus generalists should be. But when pundits talk about it they say it would be nice to aim for a fifty-fifty split.
In the last year of the first Bush presidency, this subject became hot news and was heard in discussion in many and varying arenas, To give you the conclusion of the story at the beginning, what happened is that a tremendous push went on in the United States, fostered by the government, the Robert Wood Johnson Foundation, a number of people speaking to the profession and the public, such as I, asking for the specific training of more primary care physicians, perhaps a track through medical school for primary care physicians and above all, the recognition of the tremendous amount of information that a primary care physician must know even though he may not know parts of it to the same depth the specialist in those areas could claim.
I had witnessed elsewhere on several occasions exactly the same scenario that the medical student had asked me about. I must admit that on those occasions I was absolutely furious and had I not been a guest of someone else's medical school or medical center, I would have handled the situation much differently than I did which was to keep quiet. I naturally encouraged the young man who asked the question and put down his tormentor (as gently as I could in a guest situation), and talked at length about my admiration and respect for those who went into primary care. I stressed primarily what I've mentioned above and that is the tremendous breadth of knowledge that such practitioners must have even though the depth of knowledge, understandably, cannot be as great as those who specialize in small areas. I used my own experience in pediatric surgery where my particular interest was in congenital anomalies incompatible with life, but amenable to surgical correction, and cancer, by saying that every year I learned more and more about less and less.