The Vision of the Willard Report
Still Relevant 50 Years Later
Medical practice and care were different beasts in 1966. Medicare was brand new, created July 30, 1965, not yet fully rolled out and controversial, largely due to the stigma of socialized medicine. (The American Medical Association unrelentingly opposed it!) Health insurance, where and for whom it existed, was primarily hospitalization insurance, with few benefits in the doctor’s office and little coverage for preventive services.
The US Surgeon General’s Report on Smoking (an achievement of Alabama native Dr. Luther Terry and unendorsed by the AMA for 14 years) was hot off the press from its 1964 release, and 50 percent of men, 32 percent of women and a lot of doctors in the US smoked.
There was no Nicorette, H-1 blockers or PPIs, no ACE inhibitors, statins or human insulin. The only beta agonists were epinephrine and isoproterenol, which, along with theophylline, were (risky) mainstays of asthma treatment, absent inhalable steroids. There were no lithotripters, MRIs or balloon catheters. Hepatitis C was still “non-A, non-B Hepatitis,” and the first CABG was yet to be performed.
Communities were different then, too. More people lived in rural areas, and the mobility of families was a shadow of today. Multi-generational housing, or at least proximity, was common, and family and neighborhood relationships were extensive and available as a source of social support.
Who could have envisioned how medicine would change through technical advances, or how communities would evolve in one lifetime of 50 years?
Still, not everything was so different back then. The need for, the importance and shortage of general practitioners (GPs as they were called) was recognized and a reason for concern, spurring the AMA into action. This time, they got it right.
In September 1964, the AMA Ad Hoc Committee on Education for Family Practice was appointed, chaired by then dean of the University of Kentucky School of Medicine, Dr. William R. Willard. The committee was charged with recommending an educational approach to preparing enough GPs, or family physicians, to serve the American public.
The committee consisted of 10 physicians (including two from the Deep South:Dr. William Lotterhos of Jackson, Mississippi, and Dr. Julius Michaelson of Foley, Alabama) who met 13 times to confer with numerous consultants, review “voluminous reading material” and research, and exchange ideas. Two years later, in September 1966, almost exactly 50 years ago, a report, Meeting the Challenge of Family Practice, was issued. That report is commonly called “the Willard Report” as it was heavily influenced and primarily penned by Dr. Willard, who became the founding dean of our College six years later.
“Of great importance to our College and our mission of improving the health of individuals and communities is Dr. Willard’s grasp of what we now recognize as the vital contribution of community and social determinants of health. Health is not simply determined by the cure of disease but rather is dependent on factors like social support, access to healthy food and success in addressing poverty.”
What is remarkable about the report is its vision. When used in organizational strategic planning, a vision encompasses transformational initiatives that guide growth and development. The best visions need minimal revision over their lifetime, unlike operational strategies, which typically require frequent updating.
Though few could have forecasted advances in medicine 50 years down the road, Dr. Willard nailed the role, importance and concept of the family physician relevant to high-quality, 21st Century medicine and high-performing health systems. He anticipated features of practice and care delivery overlooked for decades and that are only now being purposefully implemented in the US healthcare system. The Willard Report, as I wrote in 2012, is “as remarkably relevant today as it must have sounded extreme in 1966.”
Consider how the report describes the family physician: one who “serves as the physician of first contact,” “evaluates the patient’s total health needs,” “assumes responsibility for the patient’s comprehensive and continuous health care” and acts as “coordinator of the team that provides health services.” The language is familiar to the Patient-Centered Medical Home conversations of today, yet concepts like team-based practice were not everyday notions then.
The Willard Report set the stage for innovation in medical education: “in addition to the traditional biologic and clinical sciences, the program of preparation for family practice should have significant content in the behavioral sciences.” How far from the norm this was for medical education in 1966! The biopsychosocial model would not be described for another decade when George L. Engel maintained that despite advances in physicians’ “sophisticated scientific knowledge and technical skills about the body and its aberrations,” medicine “failed to give corresponding attention to the scientific understanding of human behavior and the psychological and social aspects of illness and patient care.”
Of great importance to our College and our mission of improving the health of individuals and communities is Dr. Willard’s grasp of what we now recognize as the vital contribution of community and social determinants of health. Health is not simply determined by the cure of disease but rather is dependent on factors like social support, access to healthy food and success in addressing poverty. The report cited the neglect of “preventive medicine and personal health maintenance and the impact of social [and] environmental… factors on the patient’s health problems,” challenging the family physician to “accept responsibility for the patient’s total health care within the context of his environment, including the community and the family or comparable social unit.” The family physician needs to “understand the economic and psychosocial barriers to medical care faced by patients, the various methods for financing health care and the problems and issues involved in adequate distribution of health care to the American people.”
Dr. Willard envisioned that preparation outside the hospital setting, in a community, was the path for trainees to “follow the course of chronic illness, to become familiar with the long-term health problems of patients, or to see disease as it occurs in the community.” Through this “unique component of family practice” that he called Community Medicine, learners can be taught “an approach to the evaluation of the health problems and needs of a community.”
“Community” has been basic to our College since its 1972 founding: from our name, Community
Health Sciences; to the two-month Community Medicine rotation during my residency here, when we lived and worked in a rural community (the rotation is back); to our mission of improving health in communities. The focus on community continues. Our innovative medical student curriculum, the Tuscaloosa Longitudinal Community Curriculum (TLC²), places students with physicians in a community for nine months in lieu of traditional “siloed” hospital-based rotations. TLC² also promises to be transformative for communities, now true partners in our education initiatives. Our fellowships equip family physicians with enhanced skills badly needed by Alabama communities—obstetrics, behavioral science, geriatrics. Social determinants of health are considered when developing care plans for patients. We are taking Community Medicine and medical education to a new level by embedding our medical students and residents, and other UA health professions faculty and students, directly in communities to learn and provide resources as part of The University of Alabama-Pickens County Partnership.
It is fitting to mark the 50th Anniversary of the Willard Report with this issue of On Rounds that highlights community aspects of our work as medical educators and providers. We are appreciative of, even humbled by, the far-sighted and enduring vision of Dr. Willard and the Ad Hoc Committee. There has been no greater influence on our College, nor arguably on the discipline of family medicine. Many barriers remain to achieving better community health, and there is still work to be done. But we are proud of our successes, and I believe Dr. Willard would be pleased, too.
—RICK STREIFFER, MD, DEAN OF THE UA COLLEGE OF COMMUNITY HEALTH SCIENCES
References and Additional Reading
Engel, George L. “The biopsychosocial model and the education of health professionals.” General hospital psychiatry 1.2 (1979): 156-165.
Willard, WR. Meeting the challenge of family practice: the report of the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education. American Medical Association, Chicago, Il, 1966.
Stephens, G. Gayle. “Our 20th anniversary year: remembering the Willard Report.” The Journal of the American Board of Family Practice/American Board of Family Practice 2.4 (1988): 288-290.
Winternitz, WW. Gibbons, AR. Dr. Willard: Educator, Administrator, Innovator. Notes on a Notable Career. Unpublished document, 1991.
Willard, WR., and Ruhe, CHW. “The Challenge of Family Practice Reconsidered.” JAMA 240.5 (1978): 454-458.