Heirs of General Practiceis a frieze of glimpses of young doctors with patients of every age--about a dozen physicians in all, who belong to the new medical specialty called family practice. They are people who have addressed themselves to a need for a unifying generalism in a world that has become greatly subdivided by specialization, physicians who work with the "unquantifiable idea that a doctor who treats your grandmother, your father, your niece, and your daughter will be more adroit in treating you."
These young men and women are seen in their examining rooms in various rural communities in Maine, but Maine is only the example. Their medical objectives, their successes, the professional obstacles they do and do not overcome are representative of any place family practitioners are working. While essential medical background is provided, McPhee's masterful approach to a trend significant to all of us is replete with affecting, and often amusing, stories about both doctors and their charges.
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Farrar, Straus and Giroux
April 01, 1996
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Excerpt from Heirs of General Practice by John McPhee
Heirs of General Practice
When Ann Dorney was seventeen years old, she thought she might decide to become a physician. Looking for advice, she arranged an interview at a university medical center, where she was asked what subspecialty she had in mind. Had she considered neonatology? Departing in confusion, she decided instead to expand her experience as a teacher of mathematics, which, in her precocity, she already was. She had tutored other students since she was fourteen years old, and she continued to do so as an undergraduate in college. She appeared to have her future framed, but then an opportunity came along to spend a four-month work term in the office of a small-town physician. He was a general practitioner, by training and definition, but the year was 1973 and the lettering on the door had changed to "FAMILY PRACTICE." She worked in his office, went with him on hospitalrounds, and attended the delivery of babies. She saw each of the other Ages of Man and an exponential variety of cases. The math teacher began to fade again, and she applied to medical schools--nearly a dozen in all. Interviews were required, and she was short of funds on which to travel. For a hundred dollars, she bought an Ameripass, which was good on any Greyhound bus going anywhere at all within a single week. Thus, for something like a hundred and sixty-eight hours she rode from city to city, slept upright, checked her suitcase in coin lockers, took off her jeans in ladies' rooms, put on a dress and nylons, and carefully set her hair before catching a local bus to the medical school. "It was a scene," she says. "It was really a scene." She chose George Washington University. As a medical freshman, when she was asked to list her preferred specialties she wrote "family practice" and left the rest of the space blank. Professors attempted to dissuade her, but they were unsuccessful.
Sue Cochran entered Radcliffe College in 1969, and after two years felt a need to go away and develop a sense of purpose. She went to work for a rural doctor. Her brother, her brother's wife, her sister, and her sister's husband were all on their way to becoming specialists in internal medicine. Her father, a teacher at Harvard Medical School, was a neonatologist--in her words, "a high-tech physician." The rural doctor was her greataunt, who was scornful of specialists of every kind. For decades, the aunt had looked after a large part of the population around two mountain towns, and she passedalong to her grandniece not only a sense of what Sue Cochran calls "the psychosocial input into physical illness" but also a desire to practice medicine in a rural area and to concentrate on prevention at least as much as cure. Of her medical siblings and siblings-in-law, she says now, "They think I'm flaky." She goes on to say, "The one who's the most supportive is my father, and even he thinks I'm pretty crazy."
David Thanhauser also dropped out for a time--but, in his case, out of medical school. After graduating from Williams College, in 1969, he spent two years in medical study at Boston University before he quit, in what he now describes as "righteous adolescent anger" --angered by the world and by society in general but more specifically because he could not accept being inside what he calls "the heart of the beast of specialty medicine." In the cancer wards, for example, he felt that "technological medicine was being carried to its extreme while the feelings of people were getting no attention." In the gynecology clinic, women--many of them Hispanic or black--were given pelvic examinations before doors that kept opening and shutting. "You learn good medicine by practicing good medicine," he says. "We were learning by practicing bad medicine." In the same era, Boston revolutionaries his age were saying that while medical students were inside the hospital learning "Band-Aid medicine" a profound malaise was outside the walls. Thanhauser retreated to rural Maine, spent something under five thousand dollars (a legacy from a grandfather) to buy fifty acres of land, and, with hammerin hand, built a small house. He thought he would give up medicine and become a teacher, but meanwhile he found work as a paramedic with generalists in Bangor. Watching these family practitioners work, he saw that they were doing an excellent job, whereas the message at Boston University had been that after people have been treated by generalists in Maine the next stop is Boston, where the damage is repaired. Before long, Thanhauser went back to medical school, but with intent to enter a family-practice residency and return to rural Maine. If such a residency had not been an option for him, his sense of conflict would not have abated and he might have abandoned medicine altogether.
Sanders Burstein, who grew up in a New York suburb, was in medical school when he made his decision, forgoing urology, oncology, nephrology, gastroenterology to characterize his future as "family practice in a rural setting." Paul Forman made the same choice at a younger age: "I knew when I was in high school that I wanted to be a country doc." Terrence Flanagan, after finishing Harvard College, went to western Ireland for a time, and decided there that he wanted to become a doctor and practice in some remote settlement in his native Maine. After enrolling in the medical school of the University of Pennsylvania, he declared his interest in family practice. "Great," said William Penn, but almost no mention was made of the topic for the next four years. At the time of Flanagan's arrival, in 1975, the family-practice office at Penn was next door to the officeof the dean; when Flanagan left, family practice was in the basement, and to get into the room you had to ask for the key. When Donna Conkling went into medicine, she had an M.A.T. in English literature from the University of Chicago. As a medical student, she was surprised one day by a resident's saying to her, "You're really smart. Why are you going into family practice?" The question seemed to her to contradict itself. Her opinion was that you had to be smart to go into family practice.
All these people--in the idiom of medical education --matched the same residency program. Specifically, they went on from medical school to complete their training at what is now called the Maine-Dartmouth Family Practice Residency, which functions principally in and close by the Kennebec Valley Medical Center, in Augusta. And so did David Jones, who knew much earlier than any of the others what he wanted to do in life. Jones is the third of five brothers. One is a nephrologist in California. Another is a cardiologist at Johns Hopkins. Their father was for many years an internist at Massachusetts General Hospital. Jones had his own idea, and he had it when he was seven. At that age, he began to say, "I am going to be a G.P. That's right, I am going to be a G.P., with a farm, a stream in my back yard, and one horse." Now, a couple of decades later, Dr. Jones has his farm, he has four horses, including an Appaloosa named Papoose, and the brooks on his land run into the Aroostook River.