Heirs of General Practice by John McPhee

Version 2

Heirs of General Practice is a collection of vignettes about some of the first family doctors in rural Maine. It is a narrative nonfiction by journalist and Pulitzer Prize winner John McPhee. Originally a three-part series in the New Yorker, the collection was put into a book. Through anecdotes, interviews, quotes, and case studies, McPhee describes a select group of young doctors transitioning from medical school to residency— to their first encounters in rural small-town medicine.

The Beginning of Family Medicine

In many ways, the group of young doctors are described as adventurous and brave— a frontier group exploring the newly made and uncharted specialty of family medicine at the time (family medicine became a specialty in 1969). These doctors had chosen to pursue family medicine over specialized medicine because they were in a way rebellious.

To the layman— the neighbor, the patient— who looked back upon the old superhuman doctor [general practitioner] with admiration, imagination, exaggeration, and nostalgia, it seemed that a form of giant had disappeared… No one seemed to be in charge. The patient, in the process was not so much quartered as diced. People were being passed like bucks— or so it seemed to them— from doctor to doctor. Even such a traditionally one-on-one event as the “complete physical” might be subdivided, as internists who did not do pelvic or rectal examinations sent their patients on to gynecologists, proctologists, or urologists… In growing numbers, they felt confused and used. Was there a doctor in the house who could still regard a patient as a person rather than a disease?

Prior to WWI, most doctors in the states were general practitioners, or G.P.s. A doctor used to go to medical school, graduate through a one-year general residency, and then go out and practice general medicine. As medical technology increased during the WWI, specialization of medicine began. Advancing of technology and the science of medicine naturally led to an exponential increase in knowledge to be learned. Experts developed. Specialty residencies were born.

But there began to be a disconnect. Patients began to be “subdivided” as the number of doctors one had to see increased. McPhee sets the book in this backdrop and shows how these family doctors in rural Maine were going against the grain and aimed to care for their patients holistically— physically, mentally, socially in the context of their families and culture. They were fighting the fragmentation and dehumanization of medicine. Moreover, they had the “idea that a doctor who treats your grandmother, your father, your niece, and your daughter will be more adroit in treating you.”

Rural Maine and The 1980s

I was pretty fascinated at some of the many cultural aspects McPhee wrote about rural Maine. One of them being “the harvest.” I tried looking online at what it was, but couldn’t find out what exactly McPhee was describing. All I know was that it involved almost every person in in rural Maine— from the elderly to the young boy and girl during a particular part of the year. It involved some kind of manual labor and long hours of the day to the point that people would have to skip school and their work to help harvest. Subsequently, many accidents and injuries would occur that the rural doctor would end up treating— The hardiness of Maine’s people, the thick skin, and honest culture of New Englanders— a world away from Chicagoans!

Other cultural anecdotes fascinated me. I remember reading about doctors and patients yearning for horses and acres of land. People longed for forests and mountains. There were small town anecdotes about farms, soft ball teams, home visits, and building school-houses!

The book however does show it’s age. In particular there are anecdotes and statements that reveal certain attitudes of race, gender, and culture of the time.

“Doctor I went to, used to be in Caribou, he closed up and went back to India. And that Korean, the only reason he had to leave was his skin was yellow and people here didn’t believe in it.”

D.P.T. “the vaccine for which can cause a baby to become retarded. This happens to an extremely low percentage of babies.” (The TDaP and pertussis vaccine are proven to not be related to autism per the CDC)

Moreover, while McPhee is an excellent writer, many of the descriptions about women were centered on their attractiveness. If you compare the descriptions of men versus women, the language used put an uneven emphasis on the sex appeal of women— this is sexist and dehumanizing. Disappointing, but not surprising for the time.

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Seen when hiking in the White Mountains in New England. (Photo © Henry Del Rosario)

My Takeaway: Medicine is a Form of Social Justice

Overall, the book is a super quick read. It is valuable in that it describes the beginning of family medicine and the kind of people who go into family medicine. These kinds of people were not doing it for the money. They weren’t doing it for the prestige. They weren’t doing it just because they find medicine a big intellectually satisfying puzzle. They saw medicine as a tool for social justice: to protect the vulnerable, to heal the sick, to elevate the lowly. They were hippies and bleeding hearts and people-people.

The book went through some of the cases against family medicine. One of them questions the adequacy of care by a doctor who is “a jack of all trades but a master of none.” My only rebuttal is that for 90% of a typical patient’s needs, a generalist is capable of handling. A vast majority of visits are for physicals, back pain, blood pressure, diabetes, stubbed toes, viral URIs, etc. For atypical cases and anything else, a family doctor should know his/her limits and when to refer. A quote I found valuable:

Referral is the fulcrum of the family practitioner’s craft. From case to case— situation to situation, medical topic to medical topic— the exact position of the fulcrum varies with the doctor. One who too readily refers patients to assorted specialists is suffering a loss of science— giving up one chance after another to add experience in manageable situations. An ideal family practitioner works not jsut within but also up to the limits of her competence, his competence— knowing precisely where those limits are. …

In some ways, a good family practitioner is not unlike a good bush pilot. There is no dearth of self-confident, highly skillful, bad bush pilots who cross the margins of heavy weather and whang into mountains. The good pilots know when to choose not to fly— know their own limitations and the limitations of their craft— and are unembarrassed by their decisions.

One Body with Many Members

I do not feel called to go into rural medicine. Most likely I will work in an urban setting in the context of underserved populations. I feel called to one day go to another country to heal and share the knowledge of medicine. Wherever, I will be I believe God is calling me to serve minorities and the economically disadvantaged.

The book is in a way very benign. It doesn’t go very much into the details of healthcare disparities or inequality in the states. It doesn’t go into the corruption and injustice of government policies, insurance companies, pharmaceuticals, and the costs of healthcare. Nor does it go into disparities of health in relation to gender, race, or class. However, it did hint at the dissatisfaction of patients in the context of a modernizing medical world.

Overall, the book I think is useful in showing the humble beginnings of family medicine and how primary care is the heart and soul of medicine. We need specialists. We need cutting-edge research and advancements in the science of medicine. But we also need more primary care doctors because this is what patients need at this present moment.

The eye cannot say to the hand, “I have no need of you,” nor again the head to the feet, “I have no need of you.” On the contrary, the parts of the body that seem to be weaker are indispensable, and on those parts of the body that we think less honorable we bestow the greater honor, and our unpresentable parts are treated with greater modesty, which our more presentable parts do not require. But God has so composed the body, giving greater honor to the part that lacked it, that there may be no division in the body, but that the members may have the same care for one another. If one member suffers, all suffer together; if one member is honored, all rejoice together.

1 Corinthians 12

Version 2

White Mountains in New Hampshire. Not Maine per say, but this mountain range does extend to a small portion of western Maine! (Photo © Henry Del Rosario)

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