ON ROUNDS | FALL 2016

BY LESLIE ZGANJAR

This year marks the 50th anniversary of Meeting the Challenge of Family Practice, a report prepared by the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education, established in 1964 by the American Medical Association. Dr. William R. Willard, founding dean of CCHS, chaired the committee, which held 13 two-day meetings in the two years leading to the 1966 release of the report. At the time, experts were calling for the need for physicians to provide continuing, comprehensive health care. The report gave rise to the specialty of family practice (now family medicine), and highlighted the need for physicians to understand the impact communities have on health and the importance of providing care in communities.

Communities have a significant bearing on the health of their residents, and because of that, care should be integrated into communities. These were among the fundamental findings of the 1966 report, Meeting the Challenge of Family Practice, known today simply as the Willard Report.

The report gave rise to the new discipline of family medicine, and it provided a focus on the importance of and the need for another new field—community medicine.

“The physician … is knowledgeable about organs and systems, and techniques, but never forgets that organs and systems are part of a whole man, that the whole man lives in a complex social setting, and that diagnosis or treatment of a part, as if it existed in isolation, often overlooks major causative factors and therapeutic opportunities,” according to the report.  “The patient’s problems should be viewed in context of … factors in the community. Physicians should understand the economic and psychosocial barriers to medical care faced by many patients.”

This was a radical notion at the time, “the opening of a field called community medicine” with the concept that communities play a role in health and that patient care should be provided in communities, says Dr. David Mathews, former  University of Alabama president who was instrumental in the creation of the College of Community Health Sciences.

“And community medicine, or community health, said you don’t just treat individuals, you have to take the whole community into consideration,” says Mathews, who later served as secretary of the US Department of Health, Education and Welfare. “This was early on when we didn’t fully appreciate what we know now, which is the high correlation between the characteristics of a community and the health of the people who live there.”

The patient’s problems should be viewed in context of … factors in the community. Physicians should understand the economic and psychosocial barriers to medical care faced by many patients.

—The Willard Report


In 1964, the American Medical Association’s Council
on Medical Education charged a committee of 10 people with the task of reviewing the past and predicting the future of medicine in the US. The report found that medicine needed a new kind of specialist, the family physician, educated to provide comprehensive personal health care within the nation’s complex healthcare system.

“Preparation of large numbers of such physicians is essential if the public is to receive maximal benefits from American medicine in the future,” according to the Willard Report. “Success will require a significant reorientation of medical education and change in the attitudes of the medical profession.”

The Willard Report defines a family physician as one who “accepts responsibility for the patient’s total health care within the context of his or her environment, including the community.” The report continues … “As family physicians acquire continuing relationships with their patients, they become highly effective in dealing with the social dimensions of their illnesses”—dimensions that include knowledge about rehabilitation and mental health resources available in communities, how to provide for unmet health needs and how to provide leadership to improve the quality and quantity of health resources and services in communities.

It is about improving the health of patients through a multi-faceted, community approach and not just with additional or more advanced medical treatment.

Dr. William R. Willard, Founding Dean of the UA College of Community Health Sciences

Dr. William R. Willard, Founding Dean of the UA College of Community Health Sciences

Using the guidelines of the Willard Report, CCHS established strong training programs in family medicine for medical students and medical school graduates.

Dr. William R. Willard, the first and founding dean of the College, who passed away in 1991, said in an earlier news article: “I hoped we could motivate students to provide human and personalized comprehensive medical care as primary care physicians and engage in significant public service.”

As early as 1956, the medical literature spoke to the need for physicians to become familiar with the mental, social and economic aspects of health. Community medicine culled from this evidence that communities impact the wellbeing of their residents and that a community’s physical and social structures directly relate to health.

“Individuals and their ill-health cannot be understood solely by looking inside their bodies and brains; one must also look inside their communities …,” according to an article published in the journal Social Science and Medicine.

Willard argued that medical education should include all aspects of treating disease, in patients and communities, which would require the integration of health care services into communities. He believed doctors had an important role to play in identifying community health issues and developing strategies to address them.

As Alabama faced a health crisis in the early 1970s, UA set out to implement this model of education and to use communities to address the state’s health problems, creating CCHS and making outreach a hallmark of the education, training and practice of its medical students, resident physicians and faculty.

“We visited and talked with a lot of people all over the state and country. We discovered that health was certainly a matter of medicine, but it was far more than that,” says Mathews, UA president at the time and now president of the Kettering Foundation in Ohio. “People were just beginning to think about very fundamental reforms in the way health was provided. In particular, we were impressed by what the University of Kentucky was doing … and with a fellow named Bill Willard.”

Willard, left, was recruited by Dr. David Mathews, right, to develop CCHS and be its first dean.

 Mathews recruited Willard in 1972 to develop CCHS and to be its first dean, giving the College one of the country’s leading authorities of the community-based approach to family medicine.

Willard and early faculty were adamant about the importance and significance of community in the College’s mission (and name).  An early internal memo read: “One distinction of the CCHS, as opposed to some traditional medical education programs, is its community service function.” That function was defined as working with communities to evaluate their health needs and helping to design programs to meet those needs.

CCHS was to be a college for community health rather than a medical school.

“If you’re dealing with the health of the community and you go to the community they say, ‘Just get us a doctor.’ But they needed more than that,” says Dr. Douglas Scutchfield, recruited to CCHS by Willard in 1974 and who was professor and chair of the Department of Family and Community Medicine. “The community needed the benefit of a whole variety of things to try and facilitate health. Socio-economic determinants of health have become much more important. Education, jobs, the environment are as important to health as is the medical care system.”

Scutchfield was a family physician in a rural eastern Kentucky community and served as a preceptor for University of Kentucky medical students before joining CCHS.

The College’s distinctive approach to medical education and training, and its belief in integrating care into communities, continues today.

“A lot of the ideas that we started at CCHS have continued to flower and grow,” says Scutchfield, who, after leaving CCHS, went on to found the Graduate School of Public Health at San Diego University and the School of Public Health at the University of Kentucky.

More than 800 third- and fourth-year medical students have received their clinical education at CCHS, and the College’s Family Medicine Residency, now the second largest in the US, has graduated 456 physicians, many of whom practice in small and rural communities and primary care shortage areas in Alabama and the Southeast. Still, estimates in the Annals of Family Medicine indicate that the US will need an additional 52,000 primary care physicians by 2025. Alabama also suffers from a shortage of primary care physicians, with 60 of the state’s 67 counties classified as having a shortage of primary care physicians.

“The job isn’t done,” Scutchfield says. “The vision is still relevant.”

Don Ivey, manager of the Center for the History of Family Medicine in Leawood, Kansas, says there is still much interest in Willard and numerous requests for the Willard Report. The center keeps copies of the report on hand so that it is readily available.

“Year in and year out, we do get inquiries on a fairly regular basis from researchers who want information on both the report and Dr. Willard, which includes leaders in the specialty,” Ivy says.

Mathews agrees that the findings in the Willard Report, which led to the creation of the specialty of family medicine and the expanded view of health care that takes communities into consideration, are as relevant today as they were at the time of the report.

There are people who recognize the community is a force in the health of people and that by doing things in the community, you can improve people’s health.”

Copyright © - The University of Alabama College of Community Health Sciences