John7

FAMILY MEDICINE VOL.43,NO.1•JANUARY2011 7

ORIGINALARTICLES

Gayle Stephens, MD, has

long been, and remains to-

day, a central igure in the

emergence and evolution o amily

medicine as a specialty. He has par-

ticipated in all phases o its develop-

ment rom general practice and has

provided thoughtul guidance con-

necting us to the past and charting

alternatives into our uture.

On this occasion o the unveiling

o a new ormat or Family Medi-

cine, it is most appropriate that we

call attention to and honor the many

contributions Gayle has made to our

discipline over the years, or his writ-

ings are seamless in time, drawing

rom history, and always looking to

the uture.

Born in 1928 in Ashburn, MO,

Gayle spent his early years there. A-

ter college he attended the Univer-

sity o Missouri School o Medicine

and graduated rom Northwestern

University Medical School with dis-

tinction in 1952. Ater completing a

rotating internship at Wesley Hos-

pital in Wichita, KS, in 1953, he en-

tered general practice in Wichita.

During his early practice years,

Gayle became part o a national de-

bate over the uture o the generalist

in American medicine. Three major

reports in 1966 were instrumental

in propelling our discipline toward

specialty status: the Folsom Report,

the Millis Report, and the Willard

Report. Though varying in details, all

called or the training o more gen-

eralist physicians. The Willard Re-

port called them amily physicians

and proposed the establishment o a

certiying Board in Family Practice.

These reports and developments over

the rst 2 decades o our new spe-

cialty are well described in a chapter

by Gayle titled “Developmental As-

sessment o Family Practice: An In-

sider’s View” that appeared in a 1987

book, Family Medicine: The Matur-

ing of a Discipline, edited by William

Doherty and colleagues.1

In 1967, 2 years beore amily

practice was approved as the 20th

specialty in American medicine, Gayle

was asked by Wesley Medical Cen-

ter to transorm the existing general

practice residency to amily practice.

He moved his practice there and was

ollowed by 1,000 o his patients dur-

ing the rst year o operation. 2 The

new amily practice residency was

one o the leading programs in the

country. It was one o the seven pro-

grams that I visited in 1969 when I

took on the same task at Sonoma

County Hospital in Santa Rosa, CA.

I will always remember Gayle’s cor-

dial and helpul advice, his thought-

ul consideration o ways orward, as

well as his emphasis on the value o

the Medical Center’s library. He was

well known to the librarians, and the

library was a major resource or him.

Gayle soon gravitated to teaching

and leadership positions, both local-

ly and nationally. He became active

in many ways beyond running the

new residency, including chairing the

Education Committee o the Kansas

Academy o Family Physicians, serv-

ing as a consultant to the Residency

Assistance Program and the Resi-

dency Review Committee or Fam-

ily Practice, as a reviewer o ederal

training grants, and as president

o the Society o Teachers o Fam-

ily Medicine (STFM) rom 1973 to

1975. He was the editor o Continu-

ing Education for the Family Physi-

cian rom 1977 to 1986.

Ater 5 years leading the Wesley

residency to its strong position as a

pioneering program, Gayle accepted

a position in 1973 as the ounding

dean o the University o Alabama’s

new School o Primary Medical Care

at Huntsville. With that School’s pro-

grams up and running, Gayle moved

to Birmingham 4 years later to chair

the University o Alabama’s Depart-

ment o Family Practice. Retiring in

1988 rom ull-time employment,

he has remained active as a proes-

sor emeritus o amily practice, in-

cluding organizing ongoing teaching

programs in physical diagnosis or

optometry students and serving as a

locum tenens or his brother Charles

in rural Kansas.

Over the years, Gayle has been

honored by many organizations.

Within amily medicine, these in-

clude the American Academy o

Family Physicians’ Thomas John-

son Award or Excellence in Family

Practice Education (1975), STFM’s

Certicate o Excellence (1980), the

W. Victor Johnson Oration Award by

From the University o Washington Schoolo Medicine (Proessor Emeritus o FamilyMedicine).

G. Gayle Stephens Festschrift JohnP.Geyman,MD

(Fam Med 2011;43(1):7-12.)

8 JANUARY2011•VOL.43,NO.1 FAMILY MEDICINE

ORIGINAL ARTICLES

the College o Family Physicians o

Canada (1992), the John G. Walsh

Founder’s Award (1996), and STFM’s

Marian Bishop Award (2005). In

2006, Gayle was elected to the In-

stitute o Medicine o the National

Academies o Science.

Selected Excerpts FromHis BibliographyGayle’s bibliography over the last

50 years has been extensive, and it

is dicult within space constraints

here to do justice to the breadth,

depth, and quality o his writings.

I will take a chronological approach

and attempt to ocus on several re-

current themes o his work. This

gives us an opportunity to see how

he has reacted to the many chang-

es in amily practice and the health

care system over these years and re-

veals how his own thinking has ma-

tured.

The Physician as Healer (1965)Not surprisingly, this subject drew

Gayle’s interest in his rst solo reer-

eed publication. This excellent article

drew attention to the potential loss

o the healing touch as the emphasis

on reductionistic scientic medicine

gathered steam. While acknowledg-

ing the importance o clinical practice

being grounded on science, he oered

these cautionary observations:

One o the paradoxes o our

time is that the healing rela-

tionship seems most in jeopardy

at a time when we need it most.

There are many orces which

threaten to depersonalize the

meeting o a doctor and patient

. . .. A preoccupation with dis-

ease instead o a person is det-

rimental to good medicine. . . .

Health is not a commodity that

can be purchased in any quanti-

ty as long as one has the money.

One can buy the mechanical ap-

purtenances o healing but one

cannot buy that essential ingre-

dient—a physician who really

cares about the patient.3

Teaching and Learningof Clinical Wisdom (1974)

Gayle’s article on this subject in

the inaugural issue o The Journal

of Family Practice in May 1974 was

to become typical o his writing—

groundbreaking in its reach and

originality. Based on an assumption

that clinical competence includes a

dimension beyond technical consider-

ations, he described the various ways

in which this is so, outlined the com-

ponent behaviors o clinical wisdom,

and set out educational objectives or

teaching them. Here are some ex-

cerpts rom this timeless article:

Every clinical diagnosis, except

the most trivial and transient,

should include an appropriate

assessment o the patient’s per-

sonality . . . The wise physician

knows that it is not enough to

determine what condition the

patient has, but also what pa-

tient has the condition. Accu-

rate personality assessment

has relevance or all aspects o

the clinical situation and en-

ables the physician to make a

number o inormed decisions

about management and to pre-

dict important characteristics

o the developing doctor-patient

relationship. . . . As in marriage,

the ongoing clinical relationship

operates under the terms o an

inormal ‘contract’ that is oten

more powerul than the ormal

one. Clinical competence is

more oten at the mercy o the

strictures o the inormal con-

tract than the und o biomed-

ical inormation the physician

possesses. One can only guess

at how oten diagnoses are de-

layed, unnecessary and risky

tests are ordered and inappro-

priate treatment prescribed

because objectivity is subvert-

ed by unrecognized personality

actors.4

Reform in the United States(1976)Here Gayle explores the history o

reorm in this country in an eort

to better understand the rise o am-

ily practice. As he wrote at the time:

How is one to understand the

development o the amily prac-

tice education movement in the

United States in the latter hal

o the twentieth century? The

time is over when it could be

dismissed as trivial or evanes-

cent. Too much has happened

in the last decade or that. Le-

gitimate questions remain, how-

ever, about the signicance o

the movement, its present and

uture growth, and its ultimate

place in American medicine....

Beginning about 1890, histo-

rians have identiied several

themes o reorm in the Unit-

ed States which have been

expressed culturally, political-

ly, and socially. Each o these

themes, agrarianism, bureau-

cratization o the proessions,

and utopianism, has inlu-

enced medicine and medical

education—rst at the turn o

the century in the activities o

the AMA in promoting public

health and in establishing the

G. Gayle Stephens, MD, during his tenure

as chair of the Family Practice Department

at the University of Alabama, Birmingham,

from 1977 to 1982.


ORIGINAL ARTICLES

natural sciences as a basis or

medical education and practice.

Since the end o World War II,

additional reorm themes have

become visible which are also

inluencing medicine. Among

these are humanism, consum-

erism, and the women’s move-

ment. It is [my] thesis that the

present vitality and uture de-

velopment o amily practice as

a discipline is more dependent

on its capacity and willingness

to be identied with these ex-

pressions o reorm than on its

negotiations and compromises

within the medical education

establishment.5

The Physician as a Moral Agent(1979) Ater delving into the history o

moral philosophy and ethics, Gay-

le describes our aspects o medical

practice that bear on this subject:

(1) the ate o altruism, (2) the style

o practice, (3) individual and group

morality, and (4) the uses o coun-

seling and psychotherapy. With re-

gard to altruism, or example, he

notes that public service is one o

the main oundations o proession-

alism. Further:

I physicians lose the compul-

sion or public service, they will

also lose the protection and pre-

rogatives or sel-discipline and

proessional autonomy that the

medical proession has enjoyed

or centuries. There is no doubt

that these have already been

seriously eroded, but the way

to repair the damage is by con-

vincing the public that physi-

cians intend to be responsible

or the public’s well-being, and

will use their power and infu-

ence to protect the weak and

the sick who are at the bot-

tom o the ladder o privilege

. . . Physicians need to keep in

touch with their own tradition

and with public welare i they

are to be considered moral by

the society that sponsors them,

and rom which they take their

strength and privilege.6

Family Medicine as CounterCulture (1979)In a talk about the uture o amily

practice presented at the 1979 An-

nual Spring Conerence o the Soci-

ety o Teachers o Family Medicine

in Denver, Gayle examined our roots

and the extent to which it was acili-

tated by various reorm initiatives o

the 1960s. He had this to say:

I have sometimes thought that

our cumulative eect on the

body politic o medicine has

been conservative more than

liberal or radical. In many

ways, by our success, we have

‘taken the heat o’ the medi-

cal proession rom the public;

thereore, the status quo is be-

ing preserved. That is conser-

vative. More radical solutions

to perceived problems will not

be imposed as long as the pub-

lic thinks that something is be-

ing done.

He went on to point out that the

rise o amily medicine drew rom

agrarianism in its commitment to

rural practice, rom utopianism in

its commitment to serving the un-

derserved, rom humanism in its

practice o personal medicine with-

out subjugation to machines, and to

consumerism by its requirements

or recertication quality assurance,

patient education, and patient ad-

vocacy. But he also concluded that

however much the new specialty

owed its start to a reorm environ-

ment, that it soon abandoned much

o that energy in its eorts to join

the medical establishment.

Gayle observed that the reorms o

the 1960s did not resolve the coun-

try’s health care problems:

The doctor shortage was short-

lived, but the maldistributions

remain. Rural communities are

medically underserved, and the

numbers o people who lack

access to ordinary medical care

have increased. The industrial-

ization o medicine has urther

attenuated the personal rela-

tionships between physicians

and patients…. There is still no

reliable, stable ‘ront door’ to the

medical care system staed by

quarterbacks, captains or senior

partners.

He concluded that amily practice

could have had much more impact

on improving the health care system

than it had:

We have expended our energy

on proessional legitimation and

enranchisement rather than

reorm.

He called on our discipline:

We need to perpetuate the re-

orm ethos, to expand our num-

bers, to join with other primary

care physicians and other spe-

cialties in working or some sort

o national health program that

will give access to everybody, re-

gardless o ability to pay . . . My

hope is that we can nd lead-

ers who are willing to rethink

the priorities o medical educa-

tion on the basis o the medical

needs o the public rather than

on the basis o preserving the

proessional sel-interest o or-

ganized medicine.7

The Intellectual Basis of Family Practice (1982)

This book was published in 1982

and ocused broadly on the knowl-

edge base o amily medicine, roles o

the amily physician, and uture di-

rections or the specialty. In his Fore-

ward to the book, Ian McWhinney,

MD, Proessor and Chair o Family

Medicine at the University o West-

ern Ontario, had this to say:

One has only to read these pag-

es to realize that they are writ-

ten by a physician who has not

only thought deeply, but also


ORIGINAL ARTICLES

elt deeply about lie and medi-

cine . . . . To read them is to see

unolded a coherent philosophy

o medicine, a philosophy which

includes technology, but places

it in its correct perspective as

servant, not master.8

Gayle noted that none o the spe-

cialties in medicine were established

on epistemological grounds but in-

stead by virtue o political, economic,

or technological actors (eg, pediat-

rics by age o patients and social

orces, otolaryngology by parts o the

body, and radiology by connection to

machines). He urther noted that:

All eorts to dene amily prac-

tice or the amily physician in

terms o technical procedures

the physician may or may not

perorm will ail i approached

as a rational problem o knowl-

edge. These are problems o

political relationships among

proessional societies within

organized medicine and have

more to do with hospitals, law-

yers, and insurance companies

than with knowledge.

Gayle saw patient management as

the sine qua non o the amily phy-

sician’s role, knowing patients by

name and carrying on therapeutic

relationships with relatively large

numbers o unselected patients with

unselected conditions over time. As

he observed:

This is what we should be

teaching and learning and

practicing. Everything else is

secondary.

But he didn’t stop there. He also

challenged us to deal eectively with

other less obvious situations, such

as these:

■ Complaints that are obscure,

vague, or undierentiated

■ Complaints that seem out o pro-

portion to physical or laboratory

ndings

■ Complaints that are unusual, bi-

zarre, non-physiologic, or non-

anatomical

■ Complaints that result rom lie

change, confict, or stress

■ Conditions that require moral or

ethical decisions9

Gatekeeper Role (1989) As amily medicine and primary care

became immersed in the managed

care movement in the late 1980s,

Gayle was one o the irst among

us to voice serious concerns about

its impact on the doctor-patient re-

lationship. In a 1989 debate on the

issue in The Journal of Family Prac-

tice, he cautioned:

My experience with contract-

ed gatekeeping is that it is an

untenable and hopelessly con-

licted role that undermines

the voluntarism and earned

trust which lie at the heart o

the amily physician’s eective-

ness. By introducing elements

o compulsion and control into

the physician-patient relation-

ship, gatekeeping transorms an

intimate, covenantal relation-

ship into a hard-edged contract

between strangers—a bad ex-

change under any circumstanc-

es. Gatekeeping involves amily

physicians in structures o pow-

er, secrecy, and risk that are

oreign to their traditions and

ideals and reduces their role to

that o a corporate watchdog.

This role is so untenable that

I predict it will be eliminated

in uture versions o managed

care.10

This insight into the potential per-

ils o gatekeeper roles was prescient,

as the public came to reject the idea

o any barriers to direct access to

specialist care. The more restrictive

HMOs soon gave way to insurers’

new products o PPOs and PSOs,

which removed gatekeeper barriers

to reerral to specialists.11 Unortu-

nately, amily medicine and primary

care were caught up in the backlash

against managed care.

Family Practice in the 1980s: A Second Decade of Essays (1990)

Many o Gayle’s essays were

brought together and published by

the STFM Foundation in 1990 as the

book Family Practice in the 1980s:

A Second Decade of Essays . This

includes essays on varied subjects

ranging rom refections on amily

practice in a market economy to clin-

ical and semi-clinical subjects and a

number o editorials written while

editing Continuing Education for

the Family Physician. This is a must

read or all o us in amily medicine

and refects the remarkable sweep

o Gayle’s thinking over the years.

Here is just one sample o the nug-

gets that ll this book, drawn rom a

talk, Refections o a Post-Flexnerian

Physician, presented to the Kaiser

Family Foundation on the Task o

Medicine in 1987:

I war is too important to be let

to generals, health is surely too

important to be let to an im-

personal proessionalism that

is bound to become coercive as

it becomes more authoritarian.

I the 20th century has learned

anything about science, it surely

is that science is not socially, po-

litically, or morally neutral. The

biological sciences, no less than

physics and engineering, must

be kept under civilian control.

Such control is an issue in ev-

ery physician-patient encoun-

ter. The pure science o medical

knowledge must be tempered

by other orms o human know-

ing, and or its own good, should

always be subject to judgment

within a larger rame o reer-

ence than itsel.12


ORIGINAL ARTICLES

After Professionalization, What?(1991)Early on, Gayle perceived the hazard

o amily medicine, in an eort to get

along in the mainstream o medical

education and practice, placing its

priorities on tting into the medical

establishment by proessionalizing

general practice. As he said in 1991:

Family practice grabbed the

rings o reorm and proession-

alization at a historically propi-

tious moment and swung high

and exhilaratingly or a while;

now we are overstretched and

in danger o losing our grip

on reorm in avor o an in-

creasingly scary ride on the

not-so-merry go-round o pro-

essionalization. In this respect

we are recapitulating the expe-

rience o the medical proession

as a whole, which throughout

its history in the United States

seems to have preerred proes-

sionalization to reorm . . . . We

all have a tremendous stake in

seeing that every citizen is in-

cluded justly. This is not like-

ly to happen i physicians are

more preoccupied with deend-

ing the proession and their

own specialty’s tur than work-

ing or airness and appropri-

ateness o medical care.13

Family Doctors as Agents of Political and Social Change(2000) At the Keystone III conerence in

Colorado in 2000, Gayle continued

his exploration o the origins o am-

ily medicine and the unnished busi-

ness o health care reorm. In his

paper on Family Doctors as Agents

o Political and Social Change, he ob-

served:

Among the lessons that ought

to have been learned during

the last 30 years is that the

‘natural’ evolution o change

is not necessarily in the pub-

lic interest; that the bête noir

o change is not necessarily

‘socialized medicine’ as the

AMA tirelessly warned us or

decades—compared to the dra-

conian intrusions o industri-

alized medicine on ree choice

and privacy; and that organized

medicine, hospitals, and medi-

cal schools are not dependable

ountains o wisdom and lead-

ership in the midst o change.

Our ‘expert’ institutions and

organizations have exposed

themselves to be bastions o

resistance, sel-interest, and

exploiters o the public purse.

More than anything else they

resemble the medieval clergy

in maintaining their death-grip

on privilege, power, and sel-ag-

grandizement.

Gayle called us to task or our ail-

ures as reormers:

On balance, I judge that we

have squandered some pub-

lic credibility in our evolution

despite our success in having

created a specialty. We prob-

ably conused the public early

on when we changed our name

rom General Practice to Fam-

ily Practice, and we conused

ourselves in drawing ner dis-

tinctions with the addition o

Family Medicine, Community

Medicine and Primary Care. We

all know the reasons or these

changes, but they held no inter-

est or the public, conveyed no

weight o meaning, and some-

times allowed us to mistake

the cart or the horse . . . . We

took a hit to our public credibil-

ity when we were suckered into

‘gatekeeping’ by managed care

organizations. We ought to have

nurtured our main asset better

and demanded rom our educa-

tional settings the permissions

and wherewithal to prepare stu-

dents and residents or ull ser-

vice practice in communities o

need.14

Remembering 40 Years, Plusor Minus (2010)

In an invited address to the lead-

ership o the American Board o

Family Medicine in 2010, Gayle was

disappointed by the decline o amily

medicine and primary care ater its

surge in the l970s and 1980s. As he

said at the time:

The task o reinvigorating ami-

ly medicine eels very much like

the same task that was aced in

the 1960s. And our strategies

seem very similar; ie, to im-

prove amily doctors through

education, redesign the system

o medical care in which they

work, and improve the quality

and scope o services. The Fu-

ture o Family Medicine Project

is a great deal more sophisticat-

ed than the Willard Report, but

the stated goal—‘to . . . trans-

orm and renew the discipline

o amily medicine to meet the

needs o patients in a changing

health care environment’15—is

amiliar, developmental, and

congruent . . . . Family physi-

cians and their proessional or-

ganizations have usually not

supported the reorms in med-

ical care that would acilitate

their goals and avor their best

interests. . . . The centerpiece o

amily practice is the durable

clinical relationship and listen-

ing is its method. Whatever we

can do to preserve and enhance

this exchange is good.2

CodaWhen I rst talked to Gayle ater

Family Medicine Editor John Saultz,

MD, had agreed that this Festschrit

on Gayle’s body o work would be an

essential part o Family Medicine’s

“new look,” he was pleased and hon-

ored that we should do this but also

wanted me to “be critical.” So here

I will try to do so, dicult as it is.

Gayle has never been one to be

overly prescriptive. In his Family

Medicine as Counter Culture talk,

he demurred in this way:


ORIGINAL ARTICLES

I do not present these ideas in

a pejorative or derogatory way. I

am attempting to describe rath-

er than judge.7

The only criticism I have is to

wish that Gayle had been more pre-

scriptive, by holding us and our or-

ganizations to even closer account

or our abandonment o reorm and

by being more outspoken about our

organizations’ conficts o interest.

Our discipline could have been more

eective in bringing orward recom-

mendations to address the increas-

ingly urgent need or a system o

universal access, but instead we

have chosen not to rock the boat.

Together with the rest o organized

medicine, we have been subsumed

without resistance by the medical

marketplace.

The last 4 decades have witnessed

an explosion o health care costs that

have priced health care beyond the

reach o much o our population. We

have a cruel and inequitable sys-

tem with tens o millions o unin-

sured and underinsured. This will

continue even ater the enactment

o health care ‘reorm’ through this

year’s Patient Protection and Aord-

able Care Act (PPACA). Crated as

it was by corporate interests, their

lobbyists and willing politicians, this

‘reorm’ law will all ar short o x-

ing the nation’s access, cost, equity,

and quality problems in our largely

or-prot, investor-owned medical in-

dustrial complex.

With the exception o some indi-

viduals within our ranks and a ew

health care organizations (eg, Physi-

cians or a National Health Program,

Physicians or Social Responsibili-

ty), medicine and amily medicine

have abdicated leadership roles to-

ward real health care reorm. We

have only to look at some o our or-

ganizations to make this point. The

Academy’s task orce on health pol-

icy never took on the issue o ask-

ing whether we should continue with

our mostly or-prot, multi-payer pri-

vate inancing system with 1,300

insurers or consider a not-or-prot

single payer system coupled with a

private delivery system. Almost all o

our medical organizations have been

in bed or decades with the drug in-

dustry, to the point that they depend

on such income or many o their ac-

tivities. How could we expect them

to advocate or patients’ interests

in having the government negoti-

ate drug prices, as the VA does so

eectively, or to allow importation

o prescription drugs rom oreign

countries? It is ironic that the Center

or the History o Family Medicine,

a project o the AAFP Foundation

which now houses all o Gayle’s col-

lected papers, is dependent on a

long list o corporate donors, includ-

ing these:16 Pinnacle Level: PhRMA

and 11 drug companies and Grand

Patron Level: 15 corporations, mostly

drug companies.

So we in amily medicine and in

our medical proession are more

complicit with today’s problems than

reormers. Our patients, neighbors,

and amilies are conronted with in-

creasing hardships in gaining access

to aordable care, and our market-

based system continues on without

much resistance or leadership rom

our proession.

But a leading light in the story

o amily medicine over the last 40

years is Gayle’s timeless voice. He

has been, and remains, by ar the

most original, thoughtul, and elo-

quent voice in our eld and among

the ew who best represents the mor-

al conscience o the entire medical

proession. His wide-ranging intel-

lect connects us with history, gives

context or where we are now, and

envisions alternative utures or our

specialty, our proession, and society.

Truly a renaissance man among us.

Thank you, Gayle, or your schol-

arship, proound insights, and gen-

tle guidance over the years; or your

dedication to the intellectual and

moral obligations o our discipline

and o medicine; or asking us to look

beyond ourselves and think over the

horizon; and or being you!

CORRESPONDENCE: Address correspondenceto Dr Geyman, 53 Avian Ridge Lane, FridayHarbor, WA 98250. 360-378-6264. Fax: 360-378-6156. [email protected].

References1. Stephens GG. Developmental assessment o

amily practice: an insider’s view. In: Doherty

WJ, Christianson CE, Sussman MD, eds. Fam-

ily medicine: maturing o a discipline. New

York: Haworth Press, 1987:1-21.

2. Stephens GG. Remembering 40 years, plus or

minus. J Am Board Fam Med 2010;Mar-Apr;23

Suppl 1:S5-S10.

3. Stephens GG. The personal touch: the physi-

cian as healer in modern society. J Kans Med

Soc 1965;66(5):237-9, 242.

4. Stephens GG. On the teaching and learning o

clinical wisdom. J Fam Pract 1974;1(1):24-7.

5. Stephens GG. Reorm in the United States: its

impact on medicine and education or amily

practice. J Fam Pract 1976;3(5):50-7.

6. Stephens GG. The physician as a moral agent.

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