REVIEWFamily medicine: its core principles and impact on patient careand medical education in the United States
Masahito Jimbo
Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University,
Philadelphia, PA, USA(Received for publication on December 10, 2003)

Abstract. The specialty of family medicine arose out of a combination of American public and professional concerns regarding fragmentation of health care and was intended to foster a type of physician with a scope of clinical competence that would allow the patient, not the disease, to be the focus.
Family physicians serve as the patient’s personal physician and provide entry to the health care system,
provide comprehensive care, maintain continuing responsibility for the patient including necessary coordination of care and referral, and provide care appropriate to the patient’s physical, emotional, andsocial needs in the context of family and community. The specialty is currently second only to internal
medicine in size, and makes a signiﬁcant contribution to patient care and medical education. As family
medicine looks to the future, some of its challenges include continuing to attract medical students tothe specialty, reﬁne research themes, and gain further acceptance in academic medical centers. (Keio J
Med 53 (2): 69–73, June 2004)
Key words: physicians, family, family practice, family medicine

cal specialization, particularly after World War II, thepercentage of general practitioners in the total physician workforce rapidly declined from 79.2% in 1938 to
17.3% in 1970.1,2In 1966, three inﬂuential reports by Willard, Millis
and Folsom for the Ad Hoc Committee on Education for Family Practice,3 the Citizens Commission on
Graduate Medical Education,4 and the National Commission on Community Health Services,5 respectively,
pointed out the lack of a competent generalist workforce and the fragmentation of medical care in the
United States. These reports consistently recommended
that the public should have access to qualiﬁed physicians who would not simply respond to isolated disease or organ dysfunction but treat them as individual
patients, provide a comprehensive scope of care that is
broad enough to treat all members of the family, andcare for them in a continuing relationship. They also
recommended that the training of this new breed ofphysicians should begin immediately and provided speciﬁc structural and content recommendations to thetraining program. The three reports provided an impetus for state legislatures, particularly in the Midwest

Introduction
Family medicine in the United States was establishedas the twentieth medical specialty in 1969. Its clinicaldiscipline was called ‘‘family practice’’, its academic
discipline ‘‘family medicine’’, and its practitioner the‘‘family practitioner’’ or ‘‘family physician’’. Althoughthese terms have been used interchangeably during its
30 plus years of existence, there currently is a pushamong its clinical and academic leadership to unify thename of the discipline as ‘‘family medicine’’ and thename of the specialty’s physician as the ‘‘family physician’’. Thus, during the subsequent discussions, theseterms will be used.
Birth of Family Medicine in the United States
Previous to the establishment of the specialty offamily medicine, primary care in the United States wasborne by the general practitioners. General practitioners typically completed one postgraduate year ofrotating internship before establishing their independent practice. However, with the acceleration of medi-

Presented at the 1314th Meeting of the Keio Medical Society in Tokyo, April 11, 2003.
Reprint requests to: Dr. Masahito Jimbo, Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, 1015
Walnut Street, Suite 401, Philadelphia, PA 19107, USA, e-mail: Masahito.Jimbo@jefferson.edu
69

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Jimbo M: Family medicine in the United Statesand West with their rural constituents, to generously
fund their state medical schools to create new departments of family medicine. This also corresponded to thegrowing public sentiment that echoed the desire for acomprehensive healthcare provider that would guidethem through the complexities of healthcare. Consequently in 1969, the American Board of Family Practice
was chartered, and in 1970, the American Academy of
Family Physicians was created. The family medicine
residency programs grew exponentially, so that by 2000,
10,503 residents trained in 472 programs distributed
across all 50 states, which is second only to internal
medicine in size. Currently, there are over 71,000 family
physicians in the United States, with the majority ofthem working in group practice.6 Of patients who indicated that they had an individual physician as a usual
source of care, 62% cited a family physician as thatsource, with an internist being second at 16%.7

latter principle of continuity of care is perhaps one of
the two most important principles of the specialty, theother being comprehensive care. The family physician
evaluates the patient’s total health needs, and provides
personal care within one or more ﬁelds of medicine.
This care emphasizes disease prevention and healthpromotion. The family physician refers the patientwhen indicated to other sources of care while preserving continuity of care. The family physician’s role as a
cost-effective coordinator of the patient’s health services is integral to the care provided. This role also
allows the family physician to serve as the patient’s
advocate in dealing with third-party payers, employers,
and others. As patient needs differ in various geographic areas, the content of a family physician’s practice varies accordingly. This is what is meant by contextual care, in that the family physician incorporates
his knowledge of the unique characteristics of the patient, family, and community into his overall care.8

Principles of Family Medicine
Clinical Content of Family Medicine
The American Academy of Family Physicians
expanded on the three aforementioned reports anddeﬁned family medicine as a medical specialty which
provides continuing and comprehensive health carefor the individual and the family. The breadth of thespecialty integrates the biological, clinical, and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system, andevery disease entity. Quality healthcare in family medicine is the achievement of optimal physical and mental
health through accessible, cost-effective care that isbased on best evidence, responsive to the needs andpreferences of patients and populations, and respectfulof patients’ families, personal values, and beliefs. Whatis unique to the specialty of family medicine are thedimensions of the process that encompass and enable
the knowledge and skill base of the family physician.
At the center of this process is the patient-physician
relationship with the patient viewed in the context ofthe family. It is the extent to which this relationship isvalued, developed, nurtured and maintained that distinguishes family medicine from all other specialties.8
There are ﬁve fundamental principles of family
medicine that underlie this process: access to care,
continuity of care, comprehensive care, coordination ofcare, and contextual care. Access of care is an important attribute, because the family physician functions as
the patient’s means of entry into the health care system.
The family physician is the physician of ﬁrst contact
in most situations and, as the initial provider, is in aunique position to form a bond with the patient. This isfurther enhanced by the longitudinal care provided by
the family physician over the patient’s lifetime; thus, thestipulation that care is not limited by age or sex. This

An oft-repeated question asked of family physiciansis the issue of comprehensiveness. To the uninformed,
it would seem next to impossible for a family physician
to take care of over 90% of a patient’s health needs
when there are countless diseases that can and do afﬂict
humans. Indeed, if all diseases existed in equal prevalence, family physicians would not be able to function
under the current description of the specialty. Fortunately, diseases differ in prevalence, and in a primarycare setting, over 90% of a particular symptom maygenerally be attributed to a handful of diseases. For
example, although there are many differential diagnosesof a chronic cough, multiple studies have shown thatin approximately 95 percent of cases in immunocompetent patients, a chronic cough of over 2 months’ duration results from postnasal-drip due to conditions of thenose and sinuses, asthma, gastroesophageal reﬂux disease, chronic bronchitis due to cigarette smoking orother irritants, bronchiectasis, eosinophilic bronchitis,or the use of an angiotensin-converting – enzyme inhibitor.9 Indeed, of all visits to family physicians, only
6.3% require referral to other physicians.6 The scopeof clinical conditions managed by family physicians isextremely broad and ranges from preventive visits suchas general medical examination, school and work physicals, through acute visits such as cough, back symptoms, chest pain and dizziness, to chronic disease management such as hypertension and diabetes mellitus.
Indeed, among patients with chronic diseases who had
an individual physician as their usual source of care,family physicians managed 62% of anxiety/depression,
60% of cancer, 67% of diabetes, 56% of heart disease,and 63% of hypertension.10

Keio J Med 2004; 53 (2): 69–73

71

In the United States, communities and corporations
do not have the practice of having their constituents
undergo preventive screening on a mass scale. Thus,
these services are provided individually by their primary care physicians, notably family physicians. It is no
surprise, then, that health promotion and disease prevention comprise much of the family physicians’ daily
workload. In an annual health maintenance visit, thepatient may receive hypertension and obesity screening, cholesterol screening, screening for cancer basedon the patient’s age and sex, immunizations, and counseling for smoking cessation, exercise, safety, and depression.11 Indeed, the science of health promotion anddisease prevention has become so complex that if family
physicians were to implement all recommendations
made by the US Preventive Services Task Force, themost authoritative and evidence-based health guidelines
in the United States, these alone would take up 7.4
hours of the physician’s time per day.12 This is but oneof the challenges family physicians face today.
Several studies have compared family physicianswith general internists. Although internists tend to believe that they see patients with more chronic diseases,
greater case severity and greater case complexity, thesestudies do not uniformly support this notion.13–17 Furthermore, studies have shown that family physicians
Table 1

saw more patients in the ofﬁce with shorter time andlower cost and resource utilization per patient, but withequal clinical outcome and patient satisfaction.13–17
These tendencies have also been veriﬁed in the hospitalsetting.18,19 Currently, 100% of clinically active family
physicians see patients in the ofﬁce, 87% care for pediatric patients, 82% see patients in the hospital, and 29%
do obstetric care.8,20
Because of the diversity and ﬂexibility inherent intheir training, family physicians have adapted well tovarious geographic settings. Perhaps this is most criticalin rural areas, where family physicians comprise thevast majority of the physician workforce. A study toillustrate this showed that if all family physicians werewithdrawn from the United States, 58% of all US
counties would become Primary Care Health Professions Shortage Areas, whereas if all general internists, pediatricians and obstetricians were similarly
withdrawn, less than 8% of counties would become
shortage areas.21
Residency Curriculum and Selection
The family medicine residency lasts three years, asis the case for internal medicine, pediatrics, and emergency medicine. Table 1 illustrates the actual curricu-

Family Medicine Residency Curriculum at Thomas Jefferson University

Rotation

Inpatient Rotations
Inpatient Family Medicine
Inpatient Family Medicine Consults
Inpatient Pediatrics
Transitional Nursery
Inpatient Obstetrics
Inpatient Surgery
Intensive Care Unit
Emergency Medicine
Pediatric Emergency Medicine
Outpatient Rotations
Family Practice Center Patients
Family Practice Center
Outpatient Pediatrics
Family Practice Obstetrics
Outpatient Gynecology
Outpatient Surgery
Outpatient Orthopedics
Sports Medicine
Cardiology
Geriatrics
Dermatology
Outpatient Subspecialties*
Elective

Postgraduate Year1

2

3

12 weeks

8 weeks

4 weeks
6 weeks

8 weeks
4 weeks
4 weeks
4 weeks
4 weeks

1 half-day/week
4 weeks

4 weeks
4 weeks

4 weeks

4 weeks

2 half-days/week
8 weeks
4 weeks
4 weeks
4 weeks

3 half-days/week

4 weeks

4 weeks
4 weeks
2 weeks
2 weeks
4 weeks

4 weeks

8 weeks

2 weeks
18 weeks
10 weeks* Includes: Otorhinolaryngology, Urology, Ophthalmology, Gastroenterology, Rheumatology, Ofﬁce Procedures, Gynecological Procedures,
Geriatric Assessment, Nursing Home, and Community Medicine.

72

lum over three years at Thomas Jefferson University.
As the residents progress from year one to three, theytake on progressively more outpatient rotations andresponsibilities. The Family Practice Center is referred
to as the ‘‘clinical home’’ of the residents, where they
not only see patients in the continuity clinic but also
learn about practice management, systems-based practice, communication and psychosocial skills, and community medicine through various outreach programs.
Although block rotations in disciplines such as pediatrics and geriatrics help consolidate knowledge and skills
relevant to that particular ﬁeld, there is a risk that once
these block rotations are completed, knowledge andskills will decline without appropriate reinforcement.
The continuity clinic, by providing a training groundfor the residents to actually evaluate patients of various
age, sex, and background with undifferentiated problems, offers such an opportunity for reinforcement andenables the residents with skills and conﬁdence to faceundifferentiated problems.22
Because real-world clinical medicine often cannot
separate patients’ biomedical from psychosocial issues,
family medicine residency programs often have on staff
behavioral specialists, such as social workers or clinicalpsychologists. They provide education in communication skills, mental health issues and management, community services, and assistance for patients in navigating through the complex maze of various insurance andhealth services.
Obstetric care in family medicine is unique in thateach resident follows several pregnant patients continuously until the completion of delivery. With the helpof an attending family physician proﬁcient in obstetrics,
the residents are able to participate in their patients’longitudinal care. However, as mentioned previously,
the fact that less than a quarter of family physicians in
active practice deliver babies has set up a debate within
the specialty leadership whether every family medicine
resident should receive obstetric training or not.20
The mission of the family medicine residency program is to train residents to become outstanding board
certiﬁed family physicians who are prepared for lifelong
learning and teaching, community service and practice.
This is accomplished by creating an environment thatemphasizes: commitment to comprehensive patient carethroughout the life cycle in the context of family andcommunity; academic excellence including attention toprinciples of education and rigorous critical thinking;and commitment to reaching out and providing carefor the under-served in the ofﬁce, the hospital and thecommunity. The Department of Family Medicine atThomas Jefferson University views resident selection asa critical process to the future of the department. Although we value academic performance through clinicalcourses, we emphasize three characteristics in selecting

Jimbo M: Family medicine in the United States

residents: highly developed interpersonal skills, unwavering commitment to patients, and a heightened senseof responsibility. All faculty and residents participate in
the interview and selection process.
Once trainees ﬁnish the residency, they are eligible
to sit for the board certifying examination and will havethe option of going directly into practice or choosing afellowship over an additional one to two years of training. The accredited clinical fellowships that would grantcertiﬁcates of added qualiﬁcation include sports medicine, adolescent medicine, and geriatrics. Additional
training also may be obtained in obstetrics and procedures such as colonoscopies for those planning to practice in rural settings, and research and teaching for
those who desire academic careers. Of note, family
medicine was the ﬁrst specialty in the United States torequire recertiﬁcation. Board-certiﬁed family physicians must successfully take a recertiﬁcation examination every seven years to remain diplomates of thespecialty.6
Undergraduate Education
Family medicine plays a key role in undergraduate
medical education. It should be noted that medical
schools in the United States are graduate schools, andthus may be entered only after completing a bachelor’s
degree in college. From the department of family medicine, ﬁrst-year medical students study various topics
in medical anthropology, culture and ethics. Firstand second-year students also undertake small groupteaching sessions where they are asked to apply thebasic science knowledge they just obtained from lectures to real clinical scenarios. The second-year
students are introduced to clinical interview and examination by taking lectures on various body system
examinations then actually interviewing and examining
patients in the hospital under close supervision by theteaching physicians.
The increasing emphasis in the United States on
ambulatory training arose due to shorter hospital stays
and sicker patients being discharged home for outpatient follow-up. Third-year medical students rotate
mandatory six-week clinical clerkships, where they are
expected to interview and examine ambulatory patientsprior to the teaching physician. The hands-on experience of seeing ten to ﬁfteen patients a day trains thestudents to gather pertinent data, establish rapport andtherapeutic alliance, and counsel and educate patientson various preventive health and acute and chronic
disease management issues. This is supplemented bylectures, grand rounds, resident morning reports andconferences, problem-based learning, home visits, community oriented primary care, and preceptorships with
community physicians. The fourth-year medical students

Keio J Med 2004; 53 (2): 69–73

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Table 2 Undergraduate Medical Education in Family Medicine atThomas Jefferson University
Education Format

Year in Medical School*

Lectures
Workshops
Small Group Teachings
Outpatient Patient Encounters
Clinical Examination Rounds
Problem-Based Learning
Home Visits
Community Medicine
Morning Reports
Grand Rounds
Resident Conferences
Community Physician Preceptorship
Outpatient Subinternship
Inpatient Subinternship
Hospital Teaching Rounds
Hospital Attending Rounds

1

2

3

4

D
D
D
D

D
D
D

D

D

D

D

D
D

D
D
D
D
D
D
D

D
D
D
D
D
D
D
D

* In the United States, medical schools are 4 years in length.

rotate as outpatient or inpatient subinterns, where theyact essentially as residents, with the exception of writingorders and prescriptions, which must always be cosigned by an actual physician. The various learning
strategies, which are summarized in Table 2, are implemented to approximate the real-life clinical setting andto enable the students to be independent, life-longlearners.
Summary
Since its inception in 1969, family medicine has
made signiﬁcant strides in patient care and medical
education. It is now the second largest specialty in the
United States, and family physicians make up the bulkof the physician workforce in rural counties. Family
physicians serve as the patient’s personal physician andprovide entry to the health care system, provide comprehensive care, maintain continuing responsibility forthe patient including necessary coordination of care andreferral, and provide care appropriate to the patient’s
physical, emotional, and social needs in the context offamily and community. As family medicine looks to the
future, some of its challenges include continuing to attract medical students to the specialty, reﬁne research
themes, and gain further acceptance in academic medical centers.
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