Plow, town, and gown: The politics of family practice in 1960s America

Bulletin of the History of Medicine

Volumn 87, Issue 4, 2013, Pages 648-680

  Tobbell, Dominique ^a  

^a UNIVERSITY OF MINNESOTA   (United States)

Author keywords

Family medicine; Family practice; General practice; Medical education; Rural medicine; Town gown

Indexed keywords

ARTICLE; GENERAL PRACTICE; HISTORY; MANPOWER; MEDICAL EDUCATION; MEDICAL SCHOOL; ORGANIZATION AND MANAGEMENT; PHYSICIAN; POLITICS; SOCIAL ENVIRONMENT; UNITED STATES;

EDUCATION, MEDICAL; FAMILY PRACTICE; HISTORY, 20TH CENTURY; MINNESOTA; PHYSICIANS; POLITICS; SCHOOLS, MEDICAL; SOCIAL ENVIRONMENT; UNITED STATES;

EID: 84890905090     PISSN: 00075140     EISSN: None     Source Type: Journal    
DOI: 10.1353/bhm.2013.0061     Document Type: Article

References (176)

1. Herb L. Huffington to Dean Robert Howard, December 7, 1965, University of Minnesota Archives, Office of the Vice President of Academic Administration Collection (hereafter OVP), box 16, Folder: Medical Sciences-Programs 1965-1966.
2. "Editorial: What Is an Internist?, " GP 28, no. 1 (1963): 79.
3. See also Ellen More's web-based historical account: "The People's Medicine Comes to Massachusetts: Establishing a Family Medicine Residency at UMass Medical School, " http:// library.umassmed.edu/omha/fmch/index.cfm (accessed October 16, 2011).
4. "Editorial: Orchids to the Richmond AGP, " GP 27, no. 2 (1963): 79.
5. Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (Oxford: Oxford University Press, 2005), 117-18.
6. "News from the State Chapters, " GP 21, no. 1 (1960): 261.
7. "Editorial: Handwriting on the Wall, " GP 26, no. 4 (1962): 79.
8. In 2010, Fitzhugh Mullan and colleagues ranked the University of Minnesota School of Medicine fourteenth of all U.S. medical schools based on the percentage of their medical graduates who pursue careers in primary care. This point will be discussed in more detail later in the article.
9. Fitzhugh Mullan, Candice Chen, Stephen Petterson, Gretchen Kolsky, and Michael Spagnola, "The Social Mission of Medical Education: Ranking the Schools, " Ann. Internal Med. 152, no. 12 (2010): 804-11, data from Appendix 2.
10. The University of Minnesota Medical School in Minneapolis was the state's only medical school until 1972, when both the University of Minnesota-Duluth Medical School and the Mayo Clinic Medical School were established.
11. I thank Naomi Rogers, after hearing an earlier version of this article at the 2010 annual meeting of the AAHM, for suggesting the term "plow" as a possible designation for the rural physicians in my story.
12. Vincent R. Hunt, "The Unifying Principles of Family Medicine: A Historical Perspective, " Rhode Island Med. 76 (1993): 351-60
13. Rosemary Stevens, "The Americanization of Family Medicine: Contradictions, Challenges, and Change, 1969-2000, " Fam. Med. 33, no. 4 (2001): 232-43
14. Robert Graham, Richard G. Roberts, Daniel J. Ostergaard, Norman B. Kahn, Jr., Perry A. Pugno, and Larry A. Green, "Family Practice in the United States: A Status Report, " J. Amer. Med. Assoc. 288, no. 9 (2002): 1097-1101.
15. For a general history of primary care in the United States, and the specific role of family medicine within it.
16. Joel D. Howell, "Reflections on the Past and Future of Primary Care, " Health Aff. 29, no. 5 (2010): 760-65.
17. G. Gayle Stephens, "Family as Counterculture, " Family Med. Teacher 11, no. 5 (1979): 14-18
18. David P. Adams, American Board of Family Practice: A History (Lexington, Ky.: American Board of Family Practice, 1999).
19. Stephens, "Family as Counterculture" (n. 12)
20. Adams, American Board (n. 12)
21. Stevens, "Americanization of Family Medicine" (n. 11).
22. For a detailed analysis of the development, evolution, and mobilization of the term "family practice" by general practitioners and the founders of the new specialty, see Adams, American Board (n. 12), esp. 17-44.
23. Stevens, "Americanization of Family Medicine" (n. 11), 235.
24. On the contrast between general practitioners and family practitioners, see also Adams, American Board (n. 12), 27.
25. Howell, "Reflections on the Past" (n. 11)
26. Stevens, "Americanization of Family Medicine" (n. 11).
27. Howell, "Reflections on the Past" (n. 11), 763.
28. For an early discussion of the shortage of rural physicians, see Lewis Mayers and Leonard Harrison, The Distribution of Physicians in the United States (New York: Rockefeller Foundation General Education Board, 1924).
29. For a critique of this and other reports predicting physician shortages, see Daniel M. Fox, Health Policies, Health Politics: The British and American Experience, 1911-1965 (Princeton, N.J.: Princeton University Press, 1986), 191-94.
30. Ludmerer, Time to Heal (n. 5), 209-15.
31. For a political history and critical analysis of American health workforce policies.
32. Daniel M. Fox, "From Piety to Platitudes to Pork: The Changing Politics of Health Workforce Policy, " J. Health Polit. Policy Law 21, no. 4 (1996): 825-44.
33. A survey conducted by the Opinion Research Corporation and funded by the AAGP in the early 1960s found that while the number of general practitioners was declining, an increasing number of specialists were practicing essentially as general practitioners. Thus for the nine out of ten Americans who reported having a family physician whom they called first in all cases of illness, frequently that family physician was a specialist rather than a selfidentified general practitioner.
34. Mac F. Cahal, "Annual Report of the Executive Director, " GP 30, no. 3 (1964): 193-203.
35. Rosemary A. Stevens, American Medicine and the Public Interest: A History of Specialization (Berkeley: University of California Press, 1998), 293-317.
36. Student membership was first reported in 1966, with only 18 such members listed. By 1970, however, the AAGP included 2,035 student members. AAGP membership data courtesy of the Center for the History of Family Medicine, obtained January 14, 2013.
37. National Center for Health Statistics, "Table 111. Doctors of Medicine in Primary Care, by Specialty: United States and Outlying U.S. Areas, Selected Years 1949-2009, " in Health, United States, 2011 (Hyattsville, Md.: Government Printing Office, 2012), 351, http:// www.cdc.gov/nchs/data/hus/hus11.pdf (accessed January 18, 2013).
38. In order, the ten largest state chapters in 1960 were California, New York, Illinois, Ohio, Texas, Pennsylvania, Michigan, Indiana, Minnesota and Wisconsin (they shared the number nine rank), and Iowa. These ten chapters remained in the top ten through 1966, when the AAGP stopped ranking chapters by size. Data from "Executive Director's Report of Membership, " AAGP Trans. (1960): 39.
39. For total MAGP membership numbers (in comparison to all other state chapters), see "Executive Director's Report on Membership, " AAGP Trans. (1961): 39.
40. "Executive Director's Report on Membership, " AAGP Trans. (1966): 45.
41. For statistics on the number of active general practitioners in Minnesota, see Health Manpower for the Upper Midwest. A Study of the Needs for Physicians and Dentists in Minnesota, North Dakota, South Dakota, and Montana (St. Paul, Minn.: Hill Family Foundation, June 1966), 104, 108.
42. Health Manpower for the Upper Midwest (n. 26), 95.
43. Health Manpower for the Upper Midwest (n. 26), 95.
44. "Editorial: Handwriting on the Wall, " GP 26, no. 4 (1962): 79.
45. Charles J. Schissel, "Letter: More to Come, " GP 24, no. 6 (1961): 23.
46. Committee on the Cost of Medical Care, Medical Care for the American People: The Final Report of the Committee on the Costs of Medical Care (Chicago: University of Chicago Press, 1932)
47. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1982), 261-66
48. Stevens, American Medicine and the Public Interest (n. 22), 170-71, 183-86.
49. Stevens, American Medicine and the Public Interest (n. 22), 298-301
50. Lewis G. Sandy, Thomas Bodenheimer, L. Gregory Pawlson, and Barbara Starfield, "The Political Economy of U.S. Primary Care, " Health Aff. 28, no. 4 (2009): 1136-45.
51. Sandy et al., "Political Economy" (n. 32), 1137-40.
52. On the massive postwar growth of federal funding for medical research, see Stephen P. Strickland, Politics, Science, and Dread Disease: A Short History of United States Medical Research Policy (Cambridge, Mass.: Harvard University Press, 1972). On the implications for medical education.
53. Dominique A. Tobbell, Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences (Berkeley: University of California Press/Milbank Books on Health and the Public, 2012), 38-44.
54. For a powerful critique of the specialist and research-oriented nature of medical education and practice in the 1960s.
55. Richard M. Magraw, Ferment in Medicine: A Study of the Essence of Medical Practice and of its New Dilemmas (Philadelphia: W.B. Saunders, 1966).
56. Hugh O. Thompson, "Modern Medical Education: Practical Medicine versus Pure Science, " GP 27, no. 3 (1963): 205-11, quotation on 207.
57. In 1956, Osler L. Peterson and coauthors published an extensive study of general practitioners in North Carolina that pointed to "inadequate clinical training for general practice. " While the study was hailed by many contemporaries as an assault on the clinical competence of general practitioners, the intent of the researchers had been "to obtain information about the general practitioner in the hope that his educational, training, and continuing professional needs would become clearer. " As such, the study served also to reinforce general practitioners' criticisms of medical schools for their failure to properly train general practitioners.
58. Osler L. Peterson, Leon P. Andrews, Robert S. Spain, and Bernard G. Greenberg, "An Analytical Study of North Carolina General Practice, 1953-1954, " J. Med. Educ. 31, no. 12, suppl. (1956): 1-165.
59. Richard D. Baldwin, "General Practice: A Concept and Its Challenges, " GP 28, no. 5 (1963): 181-89, quotation on 181.
60. Oral history interview with Dr. Davitt Felder, conducted by Dominique A. Tobbell, December 4, 2009, University of Minnesota Academic Health Center Oral History Project. See also Davitt Felder's unpublished memoir.
61. Herb L. Huffington to Dean Robert Howard (n. 1).
62. Oral history interview with Dr. Richard Magraw, conducted by Dominique A. Tobbell, July 31, 2009, University of Minnesota Academic Health Center Oral History Project
63. See also Robert Edgar Mitchell, "Town-Gown Revisited, " Virginia Medical Monthly 93 (1966): 742-45.
64. See, for example, Ludmerer's brief discussion of town and gown relations in Ludmerer, Time to Heal (n. 5), 117-18.
65. See, for example, Ludmerer's brief discussion of town and gown relations in Ludmerer, Time to Heal (n. 5), 117-18.
66. On expansion of clinical services in medical schools see Fox, Health Policies, Health Politics (n. 19), 164-65, 190-91.
67. "Statement of Policy and Implementing Resolution, " 1963, University of Minnesota Archives, Medical School (collection no. 947), box 21, Folder: Statement of Policy 1963.
68. Here, my interpretation of the impact of medical schools' clinical expansion on town-gown relations differs from Ludmerer's. Ludmerer maintains that in this period, "most private practitioners, despite occasional misgivings, remained friendly toward academic medical centers. on balance academic medical centers were thought to be supporting private practitioners and not competing with them. " Ludmerer, Time to Heal (n. 5), 117.
69. Robert B. Howard, "Statement by Dean Howard to Health Services Subcommittee of Minnesota House Appropriations Committee, " September 19, 1966, Robert Howard Information File, University of Minnesota Archives.
70. Robert Howard to Herb Huffington, December 31, 1965, OVP, box 16, Folder: Medical Sciences-Programs 1965-1966.
71. Howard, "Statement by Dean Howard" (n. 47).
72. Stanley J. Wenberg, "A Selected Summary of Certain Legislative Intent Items for the 1967 Session, " University of Minnesota Archives, Medical School Collection (no. 947), box 13, Folder: State Legislature 1962-1969.
73. Of the two delegates the MAGP sent to the AAGP congress in 1965, one was from a rural area and one was from Minneapolis. The MAGP established its House of Delegates in 1956, with representation defined as three delegates from each local chapter plus a delegate for every fifty members in each chapter. Complete listings and locations of the House of Delegates, Board of Directors, and state officers were printed in every issue of the official publication of the MAGP, Medical Diggings.
74. See, for example, Medical Diggings, September-October 1965, pp. 2-3, 23.
75. In 1961, thirty-seven House of Delegates members were from rural areas, twelve were from the Twin Cities and their suburbs; nine out of ten directors were from rural areas; and only the president-elect and vice-speaker were from the Twin Cities or suburbs. Both MAGP delegates of the AAGP congress were from rural areas.
76. In 1970, thirty-five of forty-eight House of Delegates members; ten out of twelve directors; and the president, secretary-treasurer, speaker, and vice-speaker were from rural areas. Again, both MAGP delegates to the AAGP congress were from rural areas.
77. See also John E. Smith, Minnesota Academy of Family Physicians. A Commemorative History, 1946-1996 (St. Louis Park: Minnesota Academy of Family Physicians, 1996).
78. I thank Daniel Fox for this observation.
79. For more discussion, see Daniel M. Fox, The Convergence of Science and Governance: Research, Health Policy, and American States (Berkeley: University of California Press, 2010), 10-13, 61-63.
80. The new legislators from suburban districts often "had more education, and more of them were professionals, women, and minorities" than the old rural legislators they replaced. In those states with swelling suburbs and concomitantly declining rural populations, the political influence of organized medicine, like the AAGP, was reinforced by the sensitivity of suburban legislators to the physicians and patients who lived in their districts and demanded better access to health care services.
81. Oral history interview with Vincent Hunt, conducted by Dominique A. Tobbell, February 9, 2010, University of Minnesota Academic Health Center Oral History Project, pp. 18-23.
82. In 1969, the MAGP awarded state representative Richard Fitzsimons the Certificate of Meritorious Service in recognition of his efforts to gain funding for family practice. Smith, Minnesota Academy of Family Physicians (n. 51), 34. On the political influence of Minnesota's rural physicians and the legislative power of Fitzsimons and Long, see also the oral history interview with Dr. William Jacott, conducted by Dominique A. Tobbell, June 18, 2013, University of Minnesota Academic Health Center Oral History Project, and oral history interview with Villis Vikmanis, conducted by Dominique A. Tobbell, June 21, 2013, University of Minnesota Academic Health Center Oral History Project.
83. Herb Huffington to Robert Howard, February 6, 1967, OVP, box 22, Folder: Medical Sciences-Programs 1966-1967.
84. See Stevens, American Medicine and the Public Interest (n. 22), 293-317.
85. "News from the State Chapters" (n. 6).
86. "Governor Authorizes Commission to Study Medical School Need for Long Island, " GP 22, no. 2 (1960): 201.
87. "News from the State Chapters, " GP 24, no. 1 (1961): 183.
88. General practitioners in several Midwestern states also worked with medical schools to establish two-year intensive general practice training programs, such as the programs at Indiana University Medical Center, Indianapolis and the University of Kansas Medical Center, Kansas City.
89. For example, see "University of Nebraska's Two-Year Graduate Training Program Approved, " GP 25, no. 3 (1962): 221.
90. Minnesotan general practitioners urged the state legislator and the University of Minnesota's medical school to provide incentives to medical students interested in pursing careers in general practice. In 1961, for example, the Minnesota legislature passed a bill that granted $6,000 in loans to medical students who agreed to enter general practice after graduation and practice in a town of 5,000 people or fewer for four years.
91. "Bill before Minnesota Legislature Would Draw Doctors to Small Communities, " GP 24, no. 1 (1961):
92. For more information on the establishment of general practice training programs, see Stevens, American Medicine and the Public Interest (n. 22), 293-317.
93. "MCV Heeds General Practice Need Appoints Dr. Hagood as Consultant, " GP 26, no. 2 (1962): 239-41, quotations on 241.
94. "Editorial: Orchids to the Richmond AGP, " GP 27, no. 2 (1963): 79.
95. In response, the MCV president appointed Dr. W. J. Hagood, Jr., the retired president of the Virginia Academy of General Practice, as special consultant in general practice to the medical school.
96. In that role, Hagood worked with the faculty as it reshaped the medical curriculum. "News from State Chapters, " GP 25, no. 5 (1962): 255-57.
97. Lynn P. Carmichael, "Memorandum for the Record: Virginia Trip, " May 6 1969, American Academy of General Practice Files, American Academy of Family Physicians.
98. For more on efforts by Virginia physicians to influence the medical curriculum in the state's medical schools, see Medical Society of Virginia, "Reports for the 1967 Annual Meeting, " Virginia Med. Monthly 94 (September 1967): 568-83
99. Thomas W. Murrell, Jr., "Presidential Address, " Virginia Med. Monthly 96 (February 1969): 69-72
100. Medical Society of Virginia, "Reports for the 1969 Annual Meeting, " Virginia Med. Monthly 96 (September 1969): 561-62.
101. "Editorial: Ivy-Covered Attitudes, " GP 29, no. 3 (1964): 75.
102. "Editorial: Ivy-Covered Attitudes, " GP 29, no. 3 (1964): 75.
103. Minnesota Academy of General Practice, "Commentaries on the Department of Family Practice at the University of Minnesota, September 1968, " p. 17, OVP, box 38, Folder: College of Medical Sciences Program 1968-1969.
104. Emphasis added.
105. Minnesota Academy of General Practice, "Commentaries on the Department of Family Practice at the University of Minnesota, September 1968, " p. 17, OVP, box 38, Folder: College of Medical Sciences Program 1968-1969.
106. Emphasis added.
107. Mac F. Cahal, "Annual Report of the Executive Director, " GP 32, no. 2 (1965): 219-31
108. Quotation on 223. In the mid-1960s, the AAGP assumed a more assertive role in defining the identity of general practitioners as other major groups within organized medicine, most notably the American Medical Association (AMA) and the American Association of Medical Colleges (AAMC), became interested in the shortage of generalist physicians. The AAGP perceived the growing interest of "outside groups" in the nature of generalist and later primary care as a threat to the professional autonomy and self-determination of the nation's general practitioners.
109. See Cahal, "Annual Report" (n. 21).
110. Baldwin, "General Practice" (n. 38), 183-84.
111. For more on this critique, see Magraw, Ferment in Medicine (n. 35).
112. Julius Michaelson, "Annual Report of the Chairman of the Board of Directors (1962-1963), " GP 28, no. 2 (1963): 147-54, quotation on 154.
113. Julius Michaelson, "Annual Report of the Chairman of the Board of Directors (1962-1963), " GP 28, no. 2 (1963): 147-54, quotation on 154.
114. On this point, see Stevens, American Medicine and the Public Interest (n. 22), 293-317.
115. See also Hunt, Oral history interview (n. 53).
116. See also Carruth J. Wagner, "The Needs for Medical Manpower, " GP 32, no. 1 (1965): 153-57
117. Quotation on 155, and 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: American Medical Association, September 1966).
118. Magraw, Oral history interview (n. 41).
119. Herb Huffington to Stanley Wenberg, March 23, 1968, OVP, box 29, Folder: Medical Sciences-Programs III 1967-1968.
120. Herb Huffington to Benjamin Fuller, March 19, 1968, OVP, box 29, Folder: Medical Sciences-Programs II 1967-1968.
121. Wenberg, "Selected Summary of Certain Legislative Intent Items" (n. 50).
122. Magraw, Oral history interview (n. 41).
123. John W. Lester to President Malcolm Moos, December 26, 1969, OVP, box 47, Folder: CMS Department of Family Practice and Community Health 1969-1970.
124. See also Vincent Hunt, "Comments regarding the Family Practice Department at the University of Minnesota, " April 7, 1970, OVP, box 47, Folder: CMS Department of Family Practice and Community Health, 1969-1970.
125. Robert B. Howard, "Problems Related to the Definition of Patient Population for the Department of Family Practice and Community Health, " December 1, 1969, OVP, box 47, Folder: CMS Department of Family Practice and Community Health 1969-1970.
126. Robert B. Howard, "Problems Related to the Definition of Patient Population for the Department of Family Practice and Community Health, " December 1, 1969, OVP, box 47, Folder: CMS Department of Family Practice and Community Health 1969-1970.
127. Benjamin F. Fuller, "Memorandum: Proposed Plan for Development of Patient Population for the Department of Family Practice and Community Health, " December 1, 1969, OVP, box 47, Folder: CMS Department of Family Practice and Community Health 1969-1970. For a history of closed-panel plans and health maintenance organizations.
128. Jan Gregoire Coombs, The Rise and Fall of HMOs: An American Health Care Revolution (Madison: University of Wisconsin Press, 2005).
129. Chester Anderson letter to Benjamin Fuller, December 19, 1969, OVP, box 47, Folder: CMS Department of Family Practice and Community Health 1969-1970.
130. J. A. Cosgriff, "The Section of Patient Population and Financing for the University 'Model' Family Practice Clinic, " approved by the MAGP Board of Directors, December 6, 1969, OVP, box 47, Folder: CMS Department of Family Practice and Community Health 1969-1970.
131. Hunt, "Comments regarding the Family Practice Department" (n. 79).
132. Minnesota Academy of General Practice, "A Position Paper of MAGP members on the Ad Hoc Advisory Committee to the Department of Family Practice, " March 30, 1970, OVP, box 47, Folder: CMS Department of Family Practice and Community Health 1969-1970.
133. Jack Verby, Judith Garrard, Joseph Connolly, and E. V. Lenarz, "Minnesota's Rural Physician Associate Program. First-Year Progress Report, " 1972, MSC, box 22, Folder: Executive Faculty of the Medical School 1945-1985.
134. The student was paid a stipend of $10,000, "sufficient to allow him to follow to some extent the life-style of the [physician's]" thus enabling students and their family "to realistically access their reaction to such a life, " 5611-17.
135. For a retrospective on the Rural Physician Associate Program (RPAP).
136. John E. [Jack] Verby, J. Paul Newall, Susan A. Andresen, Walter Swentko, "Changing the Medical School Curriculum to Improve Patient Access to Primary Care, " J. Amer. Med. Assoc. 266, no. 1 (1991): 110-13.
137. They report that by 1985, "the RPAP had been instrumental in providing an acceptable ratio (1:2500) of primary care physicians, mainly family physicians, for all 87 counties in Minnesota. " They also report the demonstrable effect RPAP has had on the distribution and specialty of its graduates: "Of 457 graduates in practice throughout the United States in 1991, 74% had chosen primary care, 64% had chosen family practice. Of 284 remaining in Minnesota, 88.6% were in primary care, 71% in family practice; 58.8% were in rural areas; and 68% were practicing in communities of 25,000 or fewer people. In contrast, only 51% of non-RPAP students were practicing in Minnesota, and only 18% of those were practicing in rural areas. "
138. Council of Clinical Sciences and Council of Basic Sciences, "Financing of Undergraduate Medical Education. Minutes of Meeting of the Councils of the Basic and Clinical Sciences, July 27, 1973, " MSC, box 9, Folder: Councils of the Basic and Clinical Sciences 1973.
139. On the history of the establishment of the American Board of Family Practice see Adams, American Board (n. 12).
140. Stevens, "Americanization of Family Medicine" (n. 11). For the calls of the AAGP leadership to establish a certifying board
141. Cahal, "Annual Report" (n. 69)
142. Cahal, "Annual Report of the Executive Director, " GP 35, no. 1 (1967): 189-97
143. Carroll L. Witten, "The President's Address, " GP 36, no. 2 (1967): 165-75.
144. Witten, "President's Address" (n. 88), 165-75, 225.
145. George E. Burket, Jr., "Address of the President, " GP 38, no. 1 (1968): 153.
146. George E. Burket, Jr., "The President's Address, " GP 38, no. 3 (1968): 189.
147. AAGP, "National Projection of Project MORE. The Project to Date, " Exhibit F, Board of Directors Meeting Minutes, February 3 and 4, 1962, Board of Directors Files, American Academy of Family Physicians.
148. AAGP, "Special Report to the Board of Directors on Project MORE (Pilot Phase), " Exhibit E, Board of Directors Meeting Minutes, February 3 and 4, 1962, Board of Directors Files, American Academy of Family Physicians.
149. See also "Two Preceptees in Project MORE's Pilot Program Chosen for Scholarships, " GP 25, no. 2 (1962): 213-15.
150. AAGP, "Special Report" (n. 93).
151. See also "Project for More Doctors. Sixteen-Year-Old Student Symbolizes GPs' Search for Future Physicians, " Med. World News, January 19, 1962, pp. 64-69.
152. "AAGP's Project MORE Has National Kickoff at Las Vegas Assembly, " GP 25, no. 5 (1962): 229-31.
153. "News from the State Chapters, " GP 27, no. 2 (1963): 251
154. "News from the State Chapters, " GP 27, no. 5 (1963): 231.
155. AAGP, "Report of Commission on Legislation and Public Policy, " Board of Directors Meeting Minutes, February 17-19, 1966, Board of Directors Files, American Academy of Family Physicians.
156. "News from State Chapters, " GP 38, no. 2 (1968): 257
157. "News from the State Chapters, " GP 39, no. 2 (1969): 269.
158. Medical Society of the State of New York, "News Release, " February 17, 1969, American Academy of General Practice Files, American Academy of Family Physicians.
159. "News from State Chapters, " GP 39, no. (1969): 265.
160. "The Graduate Education of Physicians. The Report of the Citizens Commission on Graduate Medical Education" (Chicago: American Medical Association, 1966), 36-37.
161. Howell, "Reflections on the Past" (n. 11), 763.
162. Witten, "President's Address" (n. 88).
163. American Academy of Family Physicians, "State Legislation and Funding for Family Practice Programs. Update through 1979" (Kansas City, Mo.: American Academy of Family Practice, 1980).
164. Activity in Family Medicine at the 125 U.S. Medical Schools and 11 Geographically Separated Campuses (Leawood, Kans.: American Academy of Family Physicians, January 2001), AAFP reprint no. 164.
165. cited in Graham et al., "Family Practice in the United States" (n. 11).
166. Graham et al., "Family Practice in the United States" (n. 11), 1099.
167. Since the early 1990s, however, the number of medical school graduates pursuing careers in primary care has been in sharp decline, and AAMC predicts that by 2020 there will be a shortage of forty-five thousand primary care physicians. Rural and nonurban areas of the country will be hardest hit by these shortages. Association of American Medical Colleges, "Physician Shortages Fact Sheet" (2010), https://www.aamc.org/download/150584/ data/physician_shortages_factsheet.pdf (accessed January 22, 2012).
168. Mullan et al., "Social Mission of Medical Education" (n. 8), data from Appendix 2. In the published article.
169. Mullan et al.'s rankings were based on three criteria: "the percentage of graduates who practice in primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score. " In the appendices to the article, they include separate data for each of these three criteria.
170. For my analysis I have focused on the data regarding only the percentage of graduates practicing primary care. It should be noted though that when the composite social mission score is used, there is little change in the general rankings of the highlighted schools.
171. Rebecca S. Lowen, Creating the Cold War University: The Transformation of Stanford (Berkeley: University of California Press, 1997)
172. Henry Etzkowitz, MIT and the Rise of Entrepreneurial Science (New York: Routledge, 2002)
173. Daniel Lee Kleinman, Impure Cultures: University Biology and the World of Commerce (Madison: University of Wisconsin Press, 2003)
174. Daniel S. Greenberg, The Politics of Pure Science (Chicago: University of Chicago Press, 1999)
175. Greenberg, Science for Sale: The Perils, Rewards, and Delusions of Campus Capitalism (Chicago: University of Chicago Press, 2007).
176. In 2001-2, on average, state and local government appropriations represented only 7.1 percent of revenue for all U.S. medical schools. Liaison Committee on Medical Education, "Annual Medical School Financial Questionnaire" (2001-2), http://www.amsa.org/ AMSA/Homepage/About/Committees/StudentLife/TuitionFAQ.aspx (accessed October 23, 2011).