| For over 80 years, concern has persisted in the United States about medicine's trajectory toward specialization and the resulting shortage of generalist physicians, who have long been considered the cornerstone of the health care system. This perpetual problem is investigated at three levels: historical, institutional, and individual. I find that the profession of medicine fails to embrace Family Medicine as an equal---a reality even when Family Medicine first became a specialty in 1969. I show that the struggle for workers is closely joined to a struggle for prestige, which points to a deeper conflict between the values of Family Medicine's holistic philosophy and the medical profession's dominant biomedical model. I argue that the medical profession withholds prestige because Family Medicine's holistic approach enlarges the boundaries of medicine in directions that threaten to undermine the purity and control of the profession's domain of expertise. I argue that this broad devaluing is an underappreciated factor in the generalist shortage, and that this disparagement operates at an institutional level through obstacles embedded in the content, culture, and structure of medical education. Of particular importance, analysis of oral histories reveals an inherent mismatch between the reported rewards of primary care, such as building relationships with patients over time, and the structure of medical training itself. Analysis of medical school mission statements examine the relationship between medical schools' unhidden curriculum and primary care, which yields a moderate correlation between the inclusion of primary care and related words and the production of primary care physicians. However, few schools (14%) of the 141 schools examined publicly value primary care in their mission statements. In light of pervasive disparagement, analysis of Family Medicine resident biosketches asks (1) why individuals commit to a specialty with such low status and (2) how these individuals construct value and appeal in their work. The presence of a social justice schema emerges, that, when embraced, renders Family Medicine as a desirable specialty and diminishes the power of the dominant narratives of disparagement. |
