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Paul M. Paulman
Robert B. Taylor
Audrey A. Paulman
Laeth S. Nasir
Editors
Family
Medicine
Principles and Practice
Eighth Edition
Family Medicine
Paul M. Paulman • Robert B. Taylor •
Audrey A. Paulman • Laeth S. Nasir
Editors
Family Medicine
Principles and Practice
Eighth Edition
With 198 figures and 357 Tables

Editors
Paul M. Paulman Robert B. Taylor
Department of Family Medicine Department of Family and Community
University of Nebraska Medical Center Medicine
Omaha, NE, USA Eastern Virginia Medical School
Norfolk, VA, USA
Oregon Health Science University
Portland, OR, USA
Audrey A. Paulman Laeth S. Nasir

Department of Family Medicine Department of Family Medicine
University of Nebraska Medical Center Creighton University School of Medicine
Omaha, NE, USA Omaha, NE, USA
ISBN 978-3-030-54440-9 ISBN 978-3-030-54441-6 (eBook)

ISBN 978-3-030-54442-3 (print and electronic bundle)
https://doi.org/10.1007/978-3-030-54441-6
1st to 6th edition: Springer-Verlag New York Inc.; 1978, 1983, 1988, 1994, 1998, 2003
7th edition: Springer International Publishing Switzerland 2017
8th edition: © Springer Nature Switzerland AG 2022
All rights are reserved by the Publisher, whether the whole or part of the material is concerned,
specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,
reproduction on microfilms or in any other physical way, and transmission or information storage
and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt
from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, expressed or implied, with respect to the material contained
herein or for any errors or omissions that may have been made. The publisher remains neutral with
regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
“Thanks to all family physicians and others who provide primary
care to their patients; without you, there would be no reason to
publish this book.”
Preface to the Eighth Edition
Family Medicine: Principles and Practice, eighth edition, is designed to

provide point of care and reference information for family physicians,
mid-level providers, residents, medical and osteopathic students, and all others
who provide primary care for patients. The supervising editors from the
seventh edition also supervised the production of this volume. The fact that
only a few chapters were removed and a few chapters added is yet another
tribute to Dr. Robert Taylor’s book design as he published the first of this series
and continues to serve on the editorial team and provide advice and counsel.
Given that this project took place during the COVID-19 pandemic, the addi-
tion of a chapter covering pandemics is very timely.
The editors are very grateful to the staff and administrators at Springer and
chapter authors who not only provided very good chapter manuscripts but also
cared for themselves and their families during this pandemic. My personal
thanks to Dr. Audrey Paulman and Dr. Laeth Nasir for their great work on the
editorial team, and of course, thank you to all our readers/users of this book, as
I said in the preface of the previous edition: providing good information which
helps our readers improve the care of their patients will be our highest marker
of success.
Stay well.
For the editors,
Omaha, USA Paul M. Paulman
December 2021 Lead Editor
vii
Preface to the First Edition
As we celebrate the publication of the 8th edition of Taylor’s Family Medicine:

Principles and Practice, we are also celebrating the 45th anniversary of the
publication of the landmark textbook Taylor’s Family Medicine: Principles
and Practice, 1st edition.
This book is about people: the patient, the family, and the family physician.
It presents health problems of the patient and health care by the physician in the
context of mankind’s most enduring societal unit – the family.
The objectives in preparation of this book have been:
1. To compile in a single textbook the fundamental principles of family

medicine and the methods to implement these principles on a global basis.
2. To describe the approach of the family physician to clinical problems.
3. To help identify the clinical content of family medicine.
4. To provide a data base which can serve as a day-by-day reference source for
the resident physician and clinician.
5. To explore the history and philosophy of the family practice movement.
These objectives were pursued by seeking the advice and participation of

family medicine educators and practitioners around the world; preparing a
book format intended to present data in a logical, cohesive manner; selecting
authors based on their interests and contributions in family medicine; consid-
ering the priorities family physicians ascribe to achieving competence in
various clinical areas; and including chapters telling the evolution of the
modern family physician and his focus on the patient in relation to the family.
A new textbook should differ significantly from other literature in the field.
The following 94 chapters represent new material prepared specifically for this
first edition, including many facts and theories never before in print. There are
several chapters giving personal viewpoints on topics pertinent to the spe-
cialty. The format employs units of sequential chapters that allow full eluci-
dation of concepts. The broad scope of family medicine is covered, including
sections on family medicine education, behavior and counseling, and the full
spectrum of clinical medicine. The development of clinical chapters has
included the Competence Priority Classification of Behavior, Concepts, and
Skills in Family Medicine, a unifying taxonomy that is intended to be aca-
demically instructive and clinically relevant.
ix
x Preface to the First Edition
The editor expresses appreciation to the 128 contributing authors and to the
four associate editors: John L. Buckingham, E. P. Donatelle, William E. Jacott,
and Melville G. Rosen. Also gratefully acknowledged is the cooperation of the
American Academy of Family Physicians, The American Board of Family
Practice, the College of Family Physicians of Canada, and the Society of
Teachers of Family Medicine. My family – Anita, Diana, and Sharon – shared
in the preparation of this book, as did literally hundreds of other persons too
numerous to list individually, and to whom the editors, authors, and readers are
indebted.
R.B.T
Acknowledgments
We dedicate this book to all the workers who labored to keep us healthy, fed,
and safe during the COVID-19 pandemic. There will never be adequate
recognition or rewards for these incredible men and women; nevertheless,
we’d like to add our thanks.
We have many more people to thank: Dr. Robert Taylor has continued to
inspire us in his role as founder of this series of reference books; his advice and
counsel have been invaluable.
Saskia Ellis, our production manager, provided a steady, consistent guiding
hand throughout the production process. When it seemed that we had reached
insurmountable roadblocks, Saskia was there to let us know how much
progress we had made and how we weren’t THAT far behind schedule. We
appreciate your work, Saskia!
Sylvia Blago has also been inspirational for us and has helped us keep our
eye on the prize. Having worked with Sylvia on previous projects, we have had
great production experiences and she did not disappoint during this project.
Thank you, Sylvia.
Our chapter authors came through with great material, while also caring for
their patients and keeping themselves and their families safe from the virus. We
are in your debt.
Personal thanks to Dr. Audrey Paulman and Dr. Laeth Nasir, volume
editors, for their great efforts to recruit chapter authors and overcome any
and all problems in order to bring this book to publication. We look forward to
future editions of this reference book from Dr. Laeth Nasir and his team. Future
editions of this book will be outstanding.
For the editors,

Paul M. Paulman
Editor
xi
Contents
Volume 1
Part I The Principles of Family Medicine . . . . . . . . . . . . . . . . . . . . . 1
1 Family Medicine: Fifty Years of Caring for America . . . . . . 3

John W. Saultz, Robert B. Taylor, and Paul M. Paulman
2 Culture, Race, and Ethnicity Issues in Health Care . . . . . . . 17
Mila Lopez, Jingnan Bu, and Michael Dale Mendoza
3 Family Issues in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . 29
Thomas L. Campbell, Susan H. McDaniel, and
Kathy Cole-Kelly
4 Family Stress and Counseling . . . . . . . . . . . . . . . . . . . . . . . . . 39
Marjorie Guthrie, Max Zubatsky, Lauren Redlinger, and
Craig W. Smith
5 Population-Based Health Care . . . . . . . . . . . . . . . . . . . . . . . . 53
Tanya E. Anim, George Rust, Cyneetha Strong, and
Joedrecka S. Brown Speights
Part II Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6 Clinical Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Roger J. Zoorob, Maria C. Mejia, and Robert S. Levine
7 Health Promotion and Wellness . . . . . . . . . . . . . . . . . . . . . . . 95
Jennifer Dalrymple, Kristen Dimas, Rose Anne Illes, and
Tyler Spradling
8 Health Care of the International Traveler . . . . . . . . . . . . . . . 107
Timothy Herrick
Part III Pregnancy, Childbirth, and Postpartum Care . . . . . . . . . . 119
9 Preconception Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Stephen D. Ratcliffe, Stephanie E. Rosener, and
Daniel J. Frayne
xiii
xiv Contents
10 Normal Pregnancy, Labor, and Delivery . . . . . . . . . . . . . . . . 137

Naureen B. Rafiq
11 Medical Problems During Pregnancy . . . . . . . . . . . . . . . . . . . 149
Matthew Halfar
12 Obstetric Complications During Pregnancy . . . . . . . . . . . . . 163
Jeffrey D. Quinlan
13 Problems During Labor and Delivery . . . . . . . . . . . . . . . . . . 177
Amanda S. Wright, Aaron Costerisan, and Kari Beth Watts
14 Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Tanya Anim, Rahmat Na’Allah, and Craig Griebel
Part IV Care of the Infant, Child, and Adolescent . . . . . . . . . . . . . 205
15 Genetic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Mylynda Beryl Massart
16 Problems of the Newborn and Infant . . . . . . . . . . . . . . . . . . . 223
Joan Younger Meek, Carlos A. Carmona, and
Emma M. Mancini
17 Infectious Diseases in Children . . . . . . . . . . . . . . . . . . . . . . . . 245
Ruba M. Jaber, Basmah M. Alnshash, and Nuha W. Qasem
18 Behavioral Problems of Children . . . . . . . . . . . . . . . . . . . . . . 263
Laeth S. Nasir and Arwa Nasir
19 Musculoskeletal Problems of Children . . . . . . . . . . . . . . . . . . 275
Christine Q. Nguyen, Carolina S. Paredes-Molina,
Trista Kleppin, Teresa Cvengros, and
George G. A. Pujalte
20 Selected Problems of Infancy and Childhood . . . . . . . . . . . . 293
Laeth S. Nasir and Arwa Nasir
21 Health Care of the Adolescent . . . . . . . . . . . . . . . . . . . . . . . . 303
W. Suzanne Eidson-Ton
Part V Care of the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
22 Selected Problems of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

Archana M. Kudrimoti
23 Common Problems of the Elderly . . . . . . . . . . . . . . . . . . . . . 329
Karenn Chan, Lesley Charles, Jean Triscott, and
Bonnie Dobbs
24 Alzheimer Disease and Other Dementias . . . . . . . . . . . . . . . . 349
Richard M. Whalen
25 Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Lana Alhalaseh, Asma Abu-Zanat, and Maram Alsmairat
Contents xv
26 Care of the Very Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Karina Isabel Bishop
Part VI Family Conflict and Violence . . . . . . . . . . . . . . . . . . . . . . . . . 375
27 Child Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

Suzanne Leonard Harrison and Mary Pfost Norton
28 Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Amy H. Buchanan and Samantha Jakuboski
29 Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Lisa M. Johnson
Part VII Behavioral and Psychiatric Problems . . . . . . . . . . . . . . . . 409
30 Managing Mentally Ill Patients in Primary Care . . . . . . . . . 411

Laeth S. Nasir
31 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Ashley Wilk, Scott G. Garland, and Niyomi DeSilva
32 Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
E. Robert Schwartz, Samir Sabbag, Ushimbra Buford,
Lainey Kieffer, and Heidi Allespach
33 The Suicidal Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Sonya R. Shipley, Molly S. Clark, and David R. Norris
34 Somatic Symptom and Related Disorders . . . . . . . . . . . . . . . 463
Kristen Dimas, Jacqueline Hidalgo, and Rose Anne Illes
35 Selected Behavioral and Psychiatric Problems . . . . . . . . . . . 471
Amy Crawford-Faucher and Daniel Deaton
36 Anxiety and Stress in Young Adults . . . . . . . . . . . . . . . . . . . . 481
Laeth S. Nasir and Amy E. Lacroix
37 Developmental Disability Across the Lifespan . . . . . . . . . . . . 489
Clarissa Kripke
Part VIII Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
38 Common Allergic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 499

M. Jawad Hashim
39 Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Alfred C. Gitu and Amy Skiff
Part IX Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
40 Epstein-Barr Virus Infection and Infectious

Mononucleosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Sahil Mullick
xvi Contents
41 Viral Infections of the Respiratory Tract . . . . . . . . . . . . . . . . 527

Lee Coghill and Alfred C. Gitu
42 Sinusitis, Tonsillitis, and Pharyngitis . . . . . . . . . . . . . . . . . . . 541
Laeth S. Nasir and Alexander Tu
43 Sexually Transmitted Diseases . . . . . . . . . . . . . . . . . . . . . . . . 551
Courtney Kimi Suh
44 Human Immunodeficiency Virus Infection and Acquired
Immunodeficiency Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 567
Mark Duane Goodman
45 Bacteremia and Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579

Omofolarin B. Fasuyi and Folashade S. Omole
46 Selected Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 587
Carlos A. Arango, Man-Kuang Chang, and L. Michael Waters
47 Epidemics and Pandemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
Mark K. Huntington
Part X Environmental and Occupational Health

Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
48 Occupational Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625

Greg Vanichkachorn, Judith Green-McKenzie, and
Edward Emmett
49 Problems Related to Physical Agents . . . . . . . . . . . . . . . . . . . 641
Hailon Wong and Aruna Khan
Part XI Injury and Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651
50 Bites and Stings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653

Brian Jobe and Laeth S. Nasir
51 Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Deepa Sharma and Nina Sharma
52 Care of Acute Lacerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Brian Frank, Dan Stein, Carl Rasmussen, Jade Koide, and
Katharine Marshall
53 Selected Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
James Hunter Winegarner
Part XII Care of the Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
54 Medical Problems of the Athlete . . . . . . . . . . . . . . . . . . . . . . . 705

T. Jason Meredith, Peter Mitchell Martin, Alison K. Bauer, and
Nathan P. Falk
Contents xvii
55 Athletic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719

T. Jason Meredith, Nathan P. Falk, Jordan Rennicke, and
Hannah Hornsby
Part XIII Common Clinical Problems . . . . . . . . . . . . . . . . . . . . . . . . . 741
56 Care of the Patient with Obesity . . . . . . . . . . . . . . . . . . . . . . . 743

Birgit Khandalavala
57 Care of the Challenging Patient . . . . . . . . . . . . . . . . . . . . . . . 751
Mark Ryan
58 Care of the Patient with Fatigue . . . . . . . . . . . . . . . . . . . . . . . 761
Sarah Louie
59 Care of the Patient with a Sleep Disorder . . . . . . . . . . . . . . . 767
J. F. Pagel
60 Medical Care of the Surgical Patient . . . . . . . . . . . . . . . . . . . 777
Nicholas Galioto and Alexandrea Jacob
61 Care of the Patient with Sexual Concerns . . . . . . . . . . . . . . . 793
Francesco Leanza and Andrea Maritato
62 Care of the Alcoholic Patient . . . . . . . . . . . . . . . . . . . . . . . . . 807
Herbert L. Muncie, Garland Anderson II, and Linda Oge
63 Care of the Patient with Chronic Pain . . . . . . . . . . . . . . . . . . 825
Faraz Ghoddusi and Kelly Bossenbroek Fedoriw
64 Care of the Dying Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835
Franklin J. Berkey and Nicki Vithalani
65 Care of the Refugee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845
Michael Greene and Seif L. Nasir
66 Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
Alicia Kowalchuk, Sandra J. Gonzalez, Maria C. Mejia, and
Roger J. Zoorob
Part XIV Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873
67 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875
D. Garcia and Faraz Ghoddusi
68 Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889
Shailendra Saxena, Sanjay Singh, Ram Sankaraneni, and
Kanishk Makhija
69 Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
Kamal C. Wagle and Cristina S. Ivan
70 Movement Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 923
Douglas J. Inciarte and Diego R. Torres-Russotto
xviii Contents
71 Disorders of the Peripheral Nervous System . . . . . . . . . . . . . 937

Kirsten Vitrikas and Norman Hurst
72 Selected Disorders of the Nervous System . . . . . . . . . . . . . . . 951
Allen Perkins, Marirose Trimmier, and Gerald Liu
Volume 2
Part XV The Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965
73 The Red Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967

Gemma Kim, Tae K. Kim, and Luanne Carlson
74 Ocular Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 983
T. Jason Meredith, Steven Embry, Ryan Hunter, and
Benjamin Noble
75 Selected Disorders of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . 993
Linda J. Vorvick and Deborah L. Lam
Part XVI The Ear, Nose, and Throat . . . . . . . . . . . . . . . . . . . . . . . . . . 1005
76 Otitis Media and Externa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007

Gretchen Irwin
77 Disorders of the Oral Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . 1015
Nicholas Galioto and Erik Egeland
78 Selected Disorders of the Ear, Nose, and Throat . . . . . . . . . . 1025
Jamie L. Krassow, Justin J. Chin, Angelique S. Forrester,
Jason J. Hofstede, and Bonnie G. Nolan
Part XVII The Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . 1041
79 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043
Kenyon Railey, Mallory Mc Clester Brown, and
Anthony J. Viera
80 Ischemic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1055
Devdutta G. Sangvai, Ashley M. Rietz, and Anthony J. Viera
81 Cardiac Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1065
Cecilia Gutierrez and Esmat Hatamy
82 Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Sophia Malary Carter, Wendy Bocaille, and
Santos Reyes-Alonso
83 Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101
Sandra Chaparro and Michael Rivera-Rodríguez
84 Cardiovascular Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . 1117
Andrea Maritato and Francesco Leanza
Contents xix
85 Venous Thromboembolism . . . . . . . . . . . . . . . . . . . . . . . . . . . 1129

Lawrence Gibbs, Josiah Moulton, and Vincent Tichenor
86 Selected Disorders of the Cardiovascular System . . . . . . . . . 1145
Philip T. Dooley and Emily M. Manlove
Part XVIII The Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167
87 Obstructive Airway Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 1169

Timothy D. Riley and Ashley Morrison
88 Pulmonary Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1183
Fiona R. Prabhu, Keeley Hobart, Irvin Sulapas, and
Amy Sikes
89 Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1203
Alap Shah and Daniel Hunter-Smith
90 Selected Disorders of the Respiratory System . . . . . . . . . . . . 1211
T. Jason Meredith, James Watson, and William Seigfreid
Part XIX The Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1225
91 Gastritis, Esophagitis, and Peptic Ulcer Disease . . . . . . . . . . 1227

Jennifer L. Grana, Christopher R. Heron, and Alan M.
Adelman
92 Diseases of the Small and Large Bowel . . . . . . . . . . . . . . . . . 1237
Corin Archuleta, Matthew Wright, Anne Marie Kennedy, and
Sara DeSpain
93 Diseases of the Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255
Douglas J. Inciarte and Daniel Ramon
94 Diseases of the Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1265
David T. O’Gurek
95 Diseases of the Rectum and Anus . . . . . . . . . . . . . . . . . . . . . . 1281
Kalyanakrishnan Ramakrishnan
96 Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1299
Thad Wilkins, Jillian Soto, Temitope I. Afon, and
Dean A. Seehusen
97 Surgical Problems of the Digestive System . . . . . . . . . . . . . . 1315
Brian Coleman and Kalyanakrishnan Ramakrishnan
98 Selected Disorders of the Digestive System . . . . . . . . . . . . . . 1337
Jason Domagalski
Part XX The Renal, Urinary, and Male Genital Systems . . . . . . . . 1347
99 Urinary Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1349

Mindy J. Lacey
xx Contents
100 Fluid, Electrolyte, and Acid–Base Disorders . . . . . . . . . . . . . 1359

KelliAnn Leli, Gwendolyn Warren, Stephen Horras,
Jennifer Bepko, and Nicholas Longstreet
101 Diseases of the Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1379

Margaret Baumgarten, Todd W. B. Gehr, Niraj R. Kothari, and
Daniel Carl
102 Benign Prostate Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . 1399

Karl T. Rew
103 Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1407

Bumsoo Park
104 Surgery of the Male Genital Tract . . . . . . . . . . . . . . . . . . . . . 1417

Karl T. Rew
105 Selected Disorders of the Genitourinary System . . . . . . . . . . 1425

Diane Holden and Paul Crawford
Part XXI The Female Reproductive System and Women’s

Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1437
106 Family Planning, Birth Control, and Contraception . . . . . . . 1439

Melanie Menning and Peter Schindler
107 Vulvovaginitis and Cervicitis . . . . . . . . . . . . . . . . . . . . . . . . . 1449

Charles Fleischer and Shermeeka Hogans-Mathews
108 Menstrual Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1463

Sabrina Hofmeister and Seth Bodden
109 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1475

Sara M. Pope, Emily Prazak, Steven ElekIV,
Timothy D. Wilcox, and Janelle K. Riley
110 Tumors of the Female Reproductive Organs . . . . . . . . . . . . . 1491

Paul Gordon, Hannah M. Emerson, Faith Dickerson,
Surbhi B. Patel, and Genevieve Riebe
111 Benign Breast Conditions and Disease . . . . . . . . . . . . . . . . . . 1507

Gabriel Briscoe, Chelsey Villanueva, Jennifer Bepko,
John Colucci, and Erin Wendt
112 Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1523

Birgit Khandalavala and J. Khandalavala
113 Selected Disorders of the Female Reproductive System . . . . 1533

Ashley Wilk, Ashley Falk, and Niyomi DeSilva
Contents xxi
Part XXII The Musculoskeletal System and Connective

Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1549
114 Disorders of the Neck and Back . . . . . . . . . . . . . . . . . . . . . . . 1551

James Winger
115 Disorders of the Upper Extremity . . . . . . . . . . . . . . . . . . . . . . 1569
Christopher Jensen
116 Disorders of the Lower Extremity . . . . . . . . . . . . . . . . . . . . . 1579
Jeff Leggit, Ryan Mark, Chad Hulsopple, Patrick M. Carey,
and Jason B. Alisangco
117 Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1605
Natasha J. Pyzocha and Douglas M. Maurer
118 Rheumatoid Arthritis and Related Disorders . . . . . . . . . . . . 1615
Scott G. Garland and Nathan P. Falk
119 Selected Disorders of the Musculoskeletal System . . . . . . . . . 1635
Patrick Anderl
Part XXIII The Skin and Subcutaneous Tissues . . . . . . . . . . . . . . . 1651
120 Common Dermatoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1653

Wanda Cruz-Knight
121 Skin Infections and Infestations . . . . . . . . . . . . . . . . . . . . . . . 1661
Micah Pippin
122 Skin Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1681
Elisabeth L. Backer
123 Selected Disorders of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . 1707
Carlton J. Covey, Stephen D. Cagle Jr, and Brett C. Johnson
Part XXIV The Endocrine and Metabolic System . . . . . . . . . . . . . . 1719
124 Dyslipidemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1721

Cezary Wójcik
125 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1735
Nadine El Asmar, Baha M. Arafah, and Charles Kent Smith
126 Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1759
Melanie Menning
127 Osteopenia and Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 1779
Katherine Reeve, Anna Meola, and Ryan West
xxii Contents
128 Disorders of Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1787

Douglas J. Inciarte and Susan Evans
129 Selected Disorders of the Endocrine and Metabolic
System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1795
Ashley Falk, Scott G. Garland, Nathan P. Falk, Dianna Pham,
and Trevor Owens
Part XXV The Blood and Hematopoietic System . . . . . . . . . . . . . . 1813
130 Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1815

Daniel T. Lee and Monica L. Plesa
131 Selected Disorders of the Blood and Hematopoietic
System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1831
Emily Emmet, Anusha Jagadish, Rajat Malik, and Raj Mehta
Part XXVI Family Medicine Applications . . . . . . . . . . . . . . . . . . . . . 1847
132 Medical Informatics, the Internet, and Telemedicine . . . . . . 1849

Michael D. Hagen
133 Complementary and Alternative Medicine . . . . . . . . . . . . . . 1859
William Hay, Laurey Steinke, and Louisa Foster
134 Patient-Centered Medical Home . . . . . . . . . . . . . . . . . . . . . . . 1875
Jumana Al-Deek, Leslie Bruce, Bianca Stewart, and Raj Mehta
135 Chronology: The Evolution of Family Practice as a
Specialty in the United States . . . . . . . . . . . . . . . . . . . . . . . . . 1883
Robert B. Taylor and Paul M. Paulman
136 Engaging the Future of Family Medicine and
Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1891
Warren P. Newton
Normal Laboratory Values/Adult Patients . . . . . . . . . . . . . . . . . . . 1901
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1903
Contributors
Asma Abu-Zanat Department of Family and Community Medicine, Univer-

sity of Jordan, Aamman, Jordan
Alan M. Adelman Family and Community Medicine, Penn State University
College of Medicine, Hershey, PA, USA
Temitope I. Afon Department of Family Medicine, Medical College of
Georgia, Augusta University, Augusta, GA, USA
Jumana Al-Deek AdventHealth Family Medicine Residency, Winter Park,
FL, USA
Lana Alhalaseh The University of Jordan, Aamman, Jordan
Jason B. Alisangco Fort Belvoir Family Medicine Department, Fort Belvoir
Community Hospital, Fort Belvoir, VA, USA
Heidi Allespach Department of Family Medicine and Community Health,
University of Miami Miller School of Medicine, Miami, FL, USA
Basmah M. Alnshash School of Medicine, University of Jordan, Jordan
University Hospital, Amman, Jordan
Maram Alsmairat Department of Family and Community Medicine, Uni-
versity of Jordan, Aamman, Jordan
Patrick Anderl Family Medicine, Univeristy of Nebraska Medical Center,
Omaha, NE, USA
Garland Anderson II Department of Family Medicine, Louisiana State
University School of Medicine, New Orleans, LA, USA
Tanya Anim College of Medicine, Family Medicine Residency Program at
Lee Health, Florida State University, Tallahassee, FL, USA
Tanya E. Anim Department of Family Medicine and Rural Health, Family
Medicine Residency Program at Lee Health, Florida State University College
of Medicine, Tallahassee, FL, USA
Baha M. Arafah Division of Clinical and Molecular Endocrinology, Uni-
versity Hospitals-Cleveland Medical Center, Case Western Reserve University
School of Medicine, Cleveland, OH, USA
xxiii
xxiv Contributors
Carlos A. Arango Department of Pediatrics, University of Florida College of

Medicine, Jacksonville, FL, USA
Corin Archuleta UNMC Family Medicine Residency Program, Omaha, NE,

USA
Elisabeth L. Backer Department of Family Medicine, University of

Nebraska Medical Center, Omaha, NE, USA
Alison K. Bauer Department of Family Medicine, University of Nebraska

Medical Center, Omaha, NE, USA
Margaret Baumgarten Family and Community Medicine, Eastern Virginia

Medical School, Norfolk, VA, USA
Jennifer Bepko David Grant Family Medicine Residency Program, David

Grant Medical Center, Fairfield, CA, USA
Franklin J. Berkey Department of Family and Community Medicine, Penn

State College of Medicine, University Park Regional Campus, State College,
PA, USA
Karina Isabel Bishop Division of Geriatrics, Gerontology and Palliative

Care, University of Nebraska Medical Center, Omaha, NE, USA
Wendy Bocaille West Kendal Baptist Hospital FIU Family Medicine Resi-
dency Program, Miami, FL, USA
Seth Bodden Medical College of Wisconsin, Milwaukee, WI, USA
Gabriel Briscoe David Grant Family Medicine Residency Program, David

Mallory Mc Clester Brown Department of Family Medicine, University of

North Carolina at Chapel Hill, Chapel Hill, NC, USA
Joedrecka S. Brown Speights Department of Family Medicine and

Rural Health, Florida State University College of Medicine, Tallahassee, FL,
USA
Leslie Bruce AdventHealth Family Medicine Residency, Winter Park, FL,

USA
Jingnan Bu Department of Family Medicine, University of Rochester

School of Medicine and Dentistry, Rochester, NY, USA
Amy H. Buchanan Stritch School of Medicine, Loyola University Health

System, Maywood, IL, USA
Ushimbra Buford Department of Psychiatry, University of Texas Health

Science Center at Tyler, Tyler, TX, USA
Stephen D. Cagle Jr Scott Family Medicine Residency Program, Scott Air

Force Base, O’Fallon, IL, USA
Contributors xxv
Thomas L. Campbell Department of Family Medicine, University of Roch-

ester School of Medicine and Dentistry, Rochester, NY, USA
Patrick M. Carey Department of Family Medicine, Uniformed Services
University of the Health Sciences, Bethesda, MD, USA
Daniel Carl Salmon Creek Medical Office, Nephrology, Vancouver, WA,
USA
Medical College of Virginia Campus, Virginia Commonwealth University,
Richmond, VA, USA
Luanne Carlson Department of Family Medicine, Desert Regional Medical
Center, Palm Springs, CA, USA
Carlos A. Carmona Pediatrics, AdventHealth, Orlando, FL, USA
Karenn Chan Division of Care of the Elderly, Department of Family Med-
icine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton,
AB, Canada
Man-Kuang Chang Baptist Primary Care, Jacksonville, FL, USA
Sandra Chaparro Florida International University, Miami, FL, USA
Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami,
FL, USA
Lesley Charles Division of Care of the Elderly, Department of Family
Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmon-
ton, AB, Canada
Justin J. Chin Family Medicine Residency Program, Eglin AFB, FL,
USA
Molly S. Clark Department of Family Medicine, University of Mississippi
Medical Center, Jackson, MS, USA
Lee Coghill Florida State University College of Medicine Family Medicine
Residency Program at Lee Health, Fort Myers, FL, USA
Kathy Cole-Kelly Case Western Reserve School of Medicine, Cleveland,
OH, USA
Brian Coleman Department of Family and Preventive Medicine, University
of Oklahoma Health Sciences Center, Oklahoma, OK, USA
John Colucci David Grant Family Medicine Residency Program, David
Aaron Costerisan Family Medicine Residency Program, University of Illi-
nois College of Medicine, Peoria, Peoria, IL, USA
Carlton J. Covey Travis Family Medicine Residency Program, Travis Air
Force Base, Fairfield, CA, USA
Paul Crawford Department of Family Medicine, Uniformed Services Uni-
versity of the Health Sciences, Bethesda, MD, USA
xxvi Contributors
Amy Crawford-Faucher Forbes Family Medicine Residency, Allegheny

Health Network, Pittsburgh, PA, USA
Wanda Cruz-Knight Family Medicine, University of South Florida Morsani
School of Medicine, Clearwater, FL, USA
GME BayCare Medical Group, Tampa, FL, USA
USF-MPM Family Medicine, Clearwater, FL, USA
Teresa Cvengros Department of Family and Community Medicine, Mount
Sinai Hospital, Chicago, IL, USA
Jennifer Dalrymple FSU Family Medicine Residency Program at Lee
Health, Fort Myers, FL, USA
Daniel Deaton Forbes Family Medicine Residency, Allegheny Health Net-
work, Pittsburgh, PA, USA
Niyomi DeSilva Florida State University College of Medicine Family Med-
icine Residency at BayCare Health System, Winter Haven, FL, USA
Sara DeSpain UNMC Family Medicine Residency Program, Omaha, NE,
USA
Faith Dickerson College of Medicine, University of Arizona, Tucson, AZ,
USA
Kristen Dimas Florida State University Family Medicine Residency Pro-
gram at Lee Health, Fort Myers, FL, USA
Bonnie Dobbs The Medically At-Risk Driver Centre, Department of Family
Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmon-
ton, AB, Canada
Jason Domagalski Medical College of Wisconsin, Menomonee Falls, WI,
USA
Philip T. Dooley Family Medicine Residency Program at Via Christi Hospi-
tals, University of Kansas School of Medicine, Wichita, KS, USA
Erik Egeland Department of Family Medicine, Broadlawns Medical Center,
Des Moines, IA, USA
W. Suzanne Eidson-Ton Department of Family and Community Medicine
and OB/GYN, University of California, Davis, Sacramento, CA, USA
Nadine El Asmar Division of Clinical and Molecular Endocrinology, Uni-
versity Hospitals-Cleveland Medical Center, Case Western Reserve University
School of Medicine, Cleveland, OH, USA
Steven Elek IV Navy Medical Center Portsmouth, Portsmouth, VA, USA
Steven Embry Department of Family Medicine, University of Nebraska
Hannah M. Emerson College of Medicine, University of Arizona, Tucson,
AZ, USA
Contributors xxvii
Emily Emmet AdventHealth Family Medicine Residency, Winter Park, FL,

USA
Edward Emmett Center of Excellence in Environmental Toxicology, Perel-

man School of Medicine, Philadelphia, PA, USA
Susan Evans Department of Family Medicine, University of Nebraska Col-

lege of Medicine, Omaha, NE, USA
Ashley Falk Florida State University College of Medicine Family Medicine

Residency at BayCare Health System, Winter Haven, FL, USA
Nathan P. Falk Florida State University College of Medicine Family Med-

icine Residency at BayCare Health System, Winter Haven, FL, USA
Omofolarin B. Fasuyi Department of Family Medicine, Morehouse School

of Medicine, Atlanta, GA, USA
Kelly Bossenbroek Fedoriw Department of Family Medicine, UNC –

Chapel Hill, Chapel Hill, NC, USA
Charles Fleischer College of Medicine, Florida State University, Tallahas-

see, FL, USA
Angelique S. Forrester Family Medicine Residency Program, Eglin AFB,

FL, USA
Louisa Foster The Center for Mindful Living, Omaha, NE, USA
Brian Frank Department of Family Medicine, Oregon Health and Science

University, Portland, OR, USA
Daniel J. Frayne MAHEC Family Health Center at Biltmore, Mountain Area

Health Education Center, Asheville, NC, USA
Nicholas Galioto Department of Family Medicine, Broadlawns Medical

Center, Des Moines, IA, USA
D. Garcia 96th Medical Group, Eglin Air Force Base, FL, USA
Scott G. Garland Florida State University College of Medicine Family

Medicine Residency at BayCare Health System, Winter Haven, FL, USA
Todd W. B. Gehr Division of Nephrology/Department of Internal Medicine,

Virginia Commonwealth University Medical College of Virginia Campus,
Richmond, VA, USA
Faraz Ghoddusi 9th Medical Group, Beale Air Force Base, Beale AFB, CA,
USA
Lawrence Gibbs Methodist Health System Family Medicine Residency,

Dallas, TX, USA
Alfred C. Gitu Florida State University College of Medicine Family Medi-

cine Residency Program at Lee Health, Fort Myers, FL, USA
xxviii Contributors
Sandra J. Gonzalez Department of Family and Community Medicine,

Baylor College of Medicine, Houston, TX, USA
Mark Duane Goodman Department of Family Medicine, Creighton Uni-
versity, Omaha, NE, USA
Paul Gordon Family and Community Medicine, University of Arizona,
College of Medicine, Tucson, AZ, USA
Jennifer L. Grana Family and Community Medicine, Penn State University
College of Medicine, Hershey, PA, USA
Michael Greene Department of Family Medicine, Alegent Creighton Clinic
John Galt, Omaha, NE, USA
Judith Green-McKenzie Division of Occupational Medicine, Department of
Emergency Medicine, Perelman School of Medicine, University of Pennsyl-
vania, Philadelphia, PA, USA
Craig Griebel Family Medicine Residency at Methodist Medical Center,
Peoria, IL, USA
Marjorie Guthrie Department of Family and Community Medicine, St.
Louis University, St. Louis, Belleville, IL, USA
Cecilia Gutierrez Department of Family Medicine and Public Health, UCSD
School of Medicine, University of California, San Diego, San Diego, CA,
USA
Michael D. Hagen Department of Family and Community Medicine, Uni-
versity of Kentucky College of Medicine, Lexington, KY, USA
Matthew Halfar Department of Family Medicine, Creighton University,
Omaha, NE, USA
Suzanne Leonard Harrison Florida State University College of Medicine,
Tallahassee, FL, USA
Esmat Hatamy Department of Family Medicine and Public Health, UCSD
School of Medicine, University of California, San Diego, San Diego, CA,
USA
William Hay Department of Family Medicine, University of Nebraska Med-
ical Center, Omaha, NE, USA
Christopher R. Heron Family and Community Medicine, Penn State Uni-
versity College of Medicine, Hershey, PA, USA
Timothy Herrick Department of Family Medicine, Oregon Health and Sci-
ence University, Portland, OR, USA
Jacqueline Hidalgo Florida State University Family Medicine Residency
Program at Lee Health, Fort Myers, FL, USA
Keeley Hobart Department of Family and Community Medicine, TTUHSC
School of Medicine, Lubbock, TX, USA
Contributors xxix
Sabrina Hofmeister Family and Community Medicine, Medical College of

Wisconsin, Milwaukee, WI, USA
Jason J. Hofstede Family Medicine Residency Program, Eglin AFB, FL,
USA
Shermeeka Hogans-Mathews College of Medicine, Florida State Univer-
sity, Tallahassee, FL, USA
Diane Holden Nellis Family Medicine Residency, Las Vegas, NV, USA
Hannah Hornsby Department of Family Medicine, University of Nebraska
Stephen Horras David Grant Family Medicine Residency Program, David
Grant Medical Center, Travis AFB, CA, USA
Chad Hulsopple Department of Family Medicine, Uniformed Services Uni-
versity of the Health Sciences, Bethesda, MD, USA
Ryan Hunter Department of Family Medicine, University of Nebraska Med-
ical Center, Omaha, NE, USA
Daniel Hunter-Smith Adventist La Grange Family Medicine Residency,
Adventist La Grange Memorial Hospital, LaGrange, IL, USA
Mark K. Huntington Center for Family Medicine, Sioux Falls, SD, USA
Department of Family Medicine, University of South Dakota Sanford School
of Medicine, Vermillion, SD, USA
Norman Hurst Family Medicine Residency, David Grant Medical Center,
Travis AFB, CA, USA
Rose Anne Illes Florida State University Family Medicine Residency Pro-
gram at Lee Health, Fort Myers, FL, USA
Douglas J. Inciarte West Kendall Baptist Health/Florida International Uni-
versity, Herbert Wertheim College of Medicine, Family Medicine Residency
Program, Florida, SW, USA
Gretchen Irwin University of Kansas School of Medicine-Wichita, Wichita,
KS, USA
Cristina S. Ivan Indiana University School of Medicine, Indianapolis, IN,
USA
Ruba M. Jaber School of Medicine, University of Jordan, Amman, Jordan
Alexandrea Jacob Broadlawns Medical Center, Des Moines, IA, USA
Anusha Jagadish AdventHealth Family Medicine Residency, Winter Park,
FL, USA
Samantha Jakuboski Stritch School of Medicine, Loyola University Health
System, Maywood, IL, USA
xxx Contributors
M. Jawad Hashim Department of Family Medicine, United Arab Emirates

University, Al-Ain, United Arab Emirates
Christopher Jensen Department of Family Medicine, University of
Brian Jobe Department of Family Medicine, LSU Health Sciences Center
Shreveport, Alexandria, LA, USA
Lisa M. Johnson Department of Family Medicine and Rural Health, Florida
State University College of Medicine, Tallahassee, FL, USA
Brett C. Johnson Travis Family Medicine Residency Program, Travis Air
Force Base, Fairfield, CA, USA
Anne Marie Kennedy UNMC Family Medicine Residency Program,
Omaha, NE, USA
Aruna Khan Florida State University Fort Myers Family Medicine Resi-
dency Program at Lee Health, Fort Myers, FL, USA
Birgit Khandalavala Department of Family Medicine, University of
J. Khandalavala Department of Obstetrics and Gynecology, Dignity Health,
Omaha, NE, USA
Lainey Kieffer Department of Family Medicine and Community Health,
University of Miami Miller School of Medicine, Miami, FL, USA
Gemma Kim Department of Family Medicine, Desert Regional Medical
Tae K. Kim Department of Family Medicine, Desert Regional Medical
Trista Kleppin Mount Sinai Hospital, Chicago, IL, USA
Jade Koide Resident Education, Kaiser Permanente, Portland, OR, USA
Niraj R. Kothari Division of Nephrology/Department of Internal Medicine,
Virginia Commonwealth University Medical College of Virginia Campus,
Richmond, VA, USA
Alicia Kowalchuk Department of Family and Community Medicine, Baylor
College of Medicine, Houston, TX, USA
Jamie L. Krassow Family Medicine Residency Program, Eglin AFB, FL,
USA
Department of Family Medicine, Uniformed Services University, Bethesda,
MD, USA
Clarissa Kripke Office of Developmental Primary Care, Department of
Family and Community Medicine, University of California, San Francisco,
CA, USA
Contributors xxxi
Archana M. Kudrimoti Department of Family and Community Medicine,

University of Kentucky, KY Clinic, Lexington, KY, USA
Mindy J. Lacey College of Medicine, University of Nebraska, Omaha, NE,
USA
Amy E. Lacroix Division of General Pediatrics, University of Nebraska
Deborah L. Lam Department of Ophthalmology, UW Medicine, University
of Washington, Seattle, WA, USA
Francesco Leanza Department of Family and Community Medicine, Fac-
ulty of Medicine, University Health Network, University of Toronto, Toronto,
ON, Canada
Daniel T. Lee Department of Family Medicine, David Geffen School of
Medicine at UCLA Health System, Santa Monica, CA, USA
Jeff Leggit Department of Family Medicine, Uniformed Services University
of the Health Sciences, Bethesda, MD, USA
KelliAnn Leli David Grant Family Medicine Residency Program, David
Grant Medical Center, Travis AFB, CA, USA
Robert S. Levine Department of Family and Community Medicine, Baylor
Gerald Liu Atrius Health, Weymouth, MA, USA
Nicholas Longstreet David Grant Family Medicine Residency Program,
David Grant Medical Center, Travis AFB, CA, USA
Mila Lopez HonorHealth Medical Group, Scottsdale, AZ, USA
Sarah Louie Community Physicians Group, UC Davis, University of Cali-
fornia, Davis, CA, USA
Kanishk Makhija Neurology, Jefferson Hospital Group, Philadelphia, PA,
USA
Sophia Malary Carter West Kendal Baptist Hospital FIU Family Medicine
Residency Program, Miami, FL, USA
FIU-Herbert Wertheim College of Medicine, Miami, FL, USA
Baptist Health Group, Family Medicine Center, Miami, FL, USA
Rajat Malik AdventHealth Family Medicine Residency, Winter Park, FL,
USA
Emma M. Mancini Pediatrics, AdventHealth, Orlando, FL, USA
Emily M. Manlove Indiana University School of Medicine, Bloomington,
IN, USA
Andrea Maritato Department of Family Medicine and Community Health,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Institute for Family Health, New York, NY, USA
xxxii Contributors
Ryan Mark Department of Family Medicine, Uniformed Services University

of the Health Sciences, Bethesda, MD, USA
Katharine Marshall Department of Internal Medicine, Providence Health
and Systems, Portland, OR, USA
Peter Mitchell Martin Department of Family Medicine, University of
Mylynda Beryl Massart Department of Family Medicine, University of
Pittsburg, UPMC-Primary Care Precision Medicine, Pittsburgh, PA, USA
Douglas M. Maurer Office of the Surgeon General Defense Health Head-
quarters, Falls Church, VA, USA
Susan H. McDaniel Department of Family Medicine, University of Roches-
ter School of Medicine, Rochester, NY, USA
Joan Younger Meek Department of Clinical Sciences, Florida State Univer-
sity College of Medicine, Orlando, FL, USA
Raj Mehta AdventHealth Family Medicine Residency, Winter Park, FL,
USA
Maria C. Mejia Department of Family and Community Medicine, Baylor
Michael Dale Mendoza Department of Family Medicine, University of
Rochester School of Medicine and Dentistry, Rochester, NY, USA
Monroe County Department of Public Health, Monroe County, NY, USA
Melanie Menning Department of Family Medicine, University of Nebraska
Anna Meola Eastern Connecticut Health Network Family Medicine Resi-
dency, Manchester, CT, USA
T. Jason Meredith Department of Family Medicine, University of Nebraska
Ashley Morrison Penn State College of Medicine, Hershey, PA, USA
Josiah Moulton Family Medicine Clinic, Hill AFB, UT, USA
Sahil Mullick Hospitalist, CHI Health Creighton University Medical Center
– Bergan Mercy Campus, Omaha, NE, USA
Creighton University Department of Family Medicine Residency Program,
Omaha, NE, USA
Herbert L. Muncie Department of Family Medicine, Louisiana State Uni-
versity School of Medicine, New Orleans, LA, USA
Rahmat Na’Allah Department of Family and Community Medicine, Uni-
versity of Illinois College of Medicine, Peoria, Family Medicine Residency
Program, Peoria, IL, USA
Contributors xxxiii
Arwa Nasir Department of Pediatrics, University of Nebraska Medical Cen-

ter, Omaha, NE, USA
Laeth S. Nasir Department of Family Medicine, Creighton University

School of Medicine, Omaha, NE, USA
Seif L. Nasir University of Nebraska Medical Center, Omaha, NE, USA
Warren P. Newton Department of Family Medicine, University of North

Carolina, Chapel Hill, NC, USA
American Board of Family Medicine, Lexington, KY, USA
Christine Q. Nguyen Department of Family Medicine, Mayo Clinic, Jack-

sonville, FL, USA
Benjamin Noble Department of Family Medicine, University of Nebraska

Bonnie G. Nolan Family Medicine Residency Program, Eglin AFB, FL,

USA
David R. Norris Department of Family Medicine, University of Mississippi

Mary Pfost Norton Florida State University College of Medicine, Tallahas-

see, FL, USA
David T. O’Gurek Department of Family and Community Medicine, Lewis

Katz School of Medicine at Temple University, Philadelphia, PA, USA
Linda Oge Department of Family Medicine, Louisiana State University

School of Medicine, New Orleans, LA, USA
Folashade S. Omole Department of Family Medicine, Morehouse School of

Medicine, Atlanta, GA, USA
Trevor Owens Florida State University College of Medicine Family Medi-

cine Residency at BayCare Health System, Winter Haven, FL, USA
J. F. Pagel Rocky Mt. Sleep, Pueblo, CO, USA

University of Colorado School of Medicine – Pueblo Family Medicine Res-
idency Program, Pueblo, CO, USA
Carolina S. Paredes-Molina Department of Family Medicine, Mayo Clinic,

Jacksonville, FL, USA
Bumsoo Park Departments of Family Medicine and Urology, University of

Michigan Medical School, Ann Arbor, MI, USA
Surbhi B. Patel College of Medicine, University of Arizona, Tucson, AZ,

USA
Paul M. Paulman Department of Family Medicine, University of Nebraska

xxxiv Contributors
Allen Perkins Department of Family Medicine, University of South Ala-

bama, Mobile, AL, USA
Dianna Pham Florida State University College of Medicine Family Medi-

cine Residency at BayCare Health System, Winter Haven, FL, USA
Micah Pippin Family Medicine, LSUHS-Shreveport Family Medicine Res-

idency, Alexandria, LA, USA
Monica L. Plesa Department of Family Medicine, David Geffen School of

Medicine at UCLA Health System, Santa Monica, CA, USA
Sara M. Pope Kaiser Permanente Washington Family Medicine Residency,

Seattle, WA, USA
Fiona R. Prabhu Department of Family and Community Medicine,

TTUHSC School of Medicine, Lubbock, TX, USA
Emily Prazak Kaiser Permanente Washington Family Medicine Residency,

Seattle, WA, USA
George G. A. Pujalte Department of Family Medicine, Mayo Clinic, Jack-

sonville, FL, USA
Natasha J. Pyzocha 98point6, Seattle, WA, USA
Nuha W. Qasem School of Medicine, Hashemite University, Zarqa, Jordan
Jeffrey D. Quinlan Department of Family Medicine, Uniformed Services

University of the Health Sciences, Bethesda, MD, USA
Naureen B. Rafiq Department of Family Medicine, Creighton University,

Omaha, NE, USA
Kenyon Railey Department of Family Medicine and Community Health,

Duke University School of Medicine, Durham, NC, USA
Kalyanakrishnan Ramakrishnan Department of Family and Preventive

Medicine, University of Oklahoma Health Sciences Center, Oklahoma, OK,
USA
Daniel Ramon West Kendall Baptist Health/Florida International University,

Herbert Wertheim College of Medicine, Family Medicine Residency Program,
Florida, SW, USA
Carl Rasmussen Department of Family Medicine, St. Luke‘s Health System,

Duluth, MN, USA
Stephen D. Ratcliffe Lancaster Health Center, Lancaster, PA, USA
Lauren Redlinger Department of Family and Community Medicine, St.

Louis University, St. Louis, Belleville, IL, USA
Katherine Reeve Yale New Haven Health Northeast Medical Group,

Uncasville, CT, USA
Contributors xxxv
Jordan Rennicke Department of Family Medicine, University of Nebraska

Karl T. Rew Departments of Family Medicine and Urology, University of
Michigan Medical School, Ann Arbor, MI, USA
Santos Reyes-Alonso West Kendal Baptist Hospital FIU Family Medicine
Residency Program, Miami, FL, USA
Genevieve Riebe Family and Community Medicine, University of Arizona,
College of Medicine, Tucson, AZ, USA
Ashley M. Rietz Department of Family Medicine, University of North Car-
olina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
Janelle K. Riley Naval Branch Health Clinic, Fallon, NV, USA
Timothy D. Riley Penn State College of Medicine, Hershey, PA, USA
Michael Rivera-Rodríguez West Kendall Baptist Hospital, Miami, FL, USA
Stephanie E. Rosener United Family Medicine Residency Program, Allina
Health, Saint Paul, MN, USA
George Rust Department of Behavioral Sciences and Social Medicine, Cen-
ter for Medicine and Public Health, Florida State University College of
Medicine, Tallahassee, FL, USA
Mark Ryan Department of Family Medicine and Population Health, Virginia
Commonwealth University School of Medicine, Richmond, VA, USA
Samir Sabbag Department of Psychiatry, Natividad Medical Center, Salinas,
CA, USA
Devdutta G. Sangvai Department of Family Medicine and Community
Health, Duke University School of Medicine, Durham, NC, USA
Ram Sankaraneni Department of Neurology, Creighton University School
of Medicine, Omaha, NE, USA
John W. Saultz Department of Family Medicine, Oregon Health and Science
Shailendra Saxena Department of Neurology, Creighton University School
of Medicine, Omaha, NE, USA
Peter Schindler Department of Family Medicine, University of Nebraska
E. Robert Schwartz Department of Family Medicine and Community
Health, University of Miami Miller School of Medicine, Miami, FL, USA
Dean A. Seehusen Department of Family Medicine, Medical College of
Georgia, Augusta University, Augusta, GA, USA
William Seigfreid Department of Family Medicine, University of Nebraska
xxxvi Contributors
Alap Shah Department of Family and Community Medicine, Adventist La

Grange Memorial Hospital Family Medicine Residency, La Grange, IL, USA
Deepa Sharma Family Medicine, Baptist Health Medical Group, Miami, FL,
USA
Nina Sharma Cardiac Critical Care/Transplant, University of Washington
Medical Center, Seattle, WA, USA
University of Washington School of Pharmacy, Seattle, WA, USA
Sonya R. Shipley Department of Family Medicine, University of Mississippi
Amy Sikes Department of Family Medicine, Texas Tech University Health
Sciences Center, Lubbock, TX, USA
Sanjay Singh Department of Neurology, Creighton University School of
Medicine, Omaha, NE, USA
Amy Skiff Florida State University College of Medicine Family Medicine
Residency Program at Lee Health, Fort Myers, FL, USA
Charles Kent Smith University Hospitals-Cleveland Medical Center, Case
Western Reserve University School of Medicine, Cleveland, OH, USA
Craig W. Smith Department of Family and Community Medicine, St. Louis
University, St. Louis, MO, USA
Jillian Soto Department of Family Medicine, Medical College of Georgia,
Augusta University, Augusta, GA, USA
Tyler Spradling FSU Family Medicine Residency Program at Lee Health,
Fort Myers, FL, USA
Dan Stein Department of Family Medicine, Oregon Health and Science
Laurey Steinke Department of Biochemistry and Molecular Biology, Uni-
versity of Nebraska Medical Center, Omaha, NE, USA
Bianca Stewart AdventHealth Family Medicine Residency, Winter Park,
FL, USA
Cyneetha Strong Department of Family Medicine and Rural Health, Florida
State University College of Medicine, Tallahassee, FL, USA
Courtney Kimi Suh Department of Family Medicine, Loyola University
Stritch School of Medicine, Maywood, IL, USA
Irvin Sulapas Department of Family and Community Medicine, Baylor
Robert B. Taylor Department of Family and Community Medicine, Eastern
Virginia Medical School, Norfolk, VA, USA
Oregon Health Science University, Portland, OR, USA
Contributors xxxvii
Vincent Tichenor Family Medicine Clinic, Barksdale AFB, LA, USA
Diego R. Torres-Russotto Department of Neurology, Movement Disorders

Division, University of Nebraska College of Medicine, Omaha, NE, USA
Marirose Trimmier Department of Family Medicine, University of South

Alabama, Mobile, AL, USA
Jean Triscott Division of Care of the Elderly, Department of Family Medi-

cine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton,
AB, Canada
Alexander Tu College of Medicine, University of Nebraska, Omaha, NE,

USA
Greg Vanichkachorn Division of Preventive, Occupational, and Aerospace

Medicine, Rochester, Minnesota, USA
Anthony J. Viera Department of Family Medicine and Community Health,

Duke University School of Medicine, Durham, NC, USA
Chelsey Villanueva David Grant Family Medicine Residency Program,

David Grant Medical Center, Fairfield, CA, USA
Nicki Vithalani Palliative Medicine, Geisinger Health System, Lewistown,

PA, USA
Kirsten Vitrikas Family Medicine Residency, David Grant Medical Center,

Travis AFB, CA, USA
Linda J. Vorvick Department of Family Medicine, UW Medicine, Univer-

sity of Washington, Seattle, WA, USA
Cezary Wójcik Oregon Health Sciences University, Portland, OR, USA
Kamal C. Wagle Indiana University School of Medicine, Indianapolis, IN,

USA
Gwendolyn Warren David Grant Family Medicine Residency Program,

David Grant Medical Center, Travis AFB, CA, USA
L. Michael Waters Department of Community Health and Family Medicine,

University of Florida College of Medicine, Jacksonville, FL, USA
James Watson Department of Family Medicine, University of Nebraska

Kari Beth Watts Family Medicine Residency Program, University of Illinois

College of Medicine, Peoria, Peoria, IL, USA
Erin Wendt David Grant Family Medicine Residency Program, David Grant
Medical Center, Fairfield, CA, USA
Ryan West Nellis Family Medicine Residency, Nellis AFB, Las Vegas, NV,
USA
xxxviii Contributors
Richard M. Whalen Department of Family Medicine, Eastern Virginia

Medical School, Norfolk, VA, USA
Timothy D. Wilcox U.S. Naval Hospital Guam, Tutuhan, Guam
Ashley Wilk Florida State University College of Medicine Family Medicine
Residency at BayCare Health System, Winter Haven, FL, USA
Thad Wilkins Department of Family Medicine, Medical College of Georgia,
Augusta University, Augusta, GA, USA
James Hunter Winegarner San Antonio Military Medical Center, Fort Sam
Houston, TX, USA
James Winger Department of Family Medicine, Loyola University Chicago
Stritch School of Medicine, Maywood, IL, USA
Hailon Wong Florida State University Fort Myers Family Medicine Resi-
dency Program at Lee Health, Fort Myers, FL, USA
Amanda S. Wright Marian University College of Osteopathic Medicine,
Indianapolis, IN, USA
Matthew Wright UNMC Family Medicine Residency Program, Omaha,
NE, USA
Roger J. Zoorob Department of Family and Community Medicine, Baylor
Max Zubatsky Department of Family and Community Medicine, St. Louis
University, St. Louis, MO, USA
Abbreviations
ACE Angiotensin-converting enzyme

ACTH Adrenocorticotropic hormone
AIDS Acquired immunodeficiency syndrome
ALT Alanine aminotransferase (SGPT)
ANA Antinuclear antibody
AST Aspartate aminotransferase (SGOT)
bid Twice a day
BP Blood pressure
bpm Beats per minute
BS Blood sugar
BUN Blood urea nitrogen
CBC Complete blood count
CHF Congestive heart failure
Cl– Chloride
CO2 Carbon dioxide
COPD Chronic obstructive pulmonary disease
CPR Cardiopulmonary resuscitation
CSF Cerebrospinal fluid
CT Computed tomography
cu mm Cubic millimeter
CXR Chest X-ray
d Day, daily
dL Deciliter
DM Diabetes mellitus
ECG Electrocardiogram
ESR Erythrocyte sedimentation rate
FDA United States Food and Drug Administration
FM Family medicine
FP Family physician
g Gram
GI Gastrointestinal
Hb Hemoglobin
Hg Mercury
HIV Human immunodeficiency virus
HMO Health maintenance organization
hr Hour
xxxix
xl Abbreviations
hs Hour of sleep, at bedtime

HTN Hypertension
IM Intramuscular
INR International normalized ratio
IU International unit
IV Intravenous
K+ Potassium
kg Kilogram
L Liter
LD or LDH Lactate dehydrogenase
mEq Milliequivalent
μg Microgram
mg Milligram
min Minute
mL Milliliter
mm Millimeter
mm3 Cubic millimeter
MRI Magnetic resonance imaging
Na+ Sodium
NSAID Nonsteroidal anti-inflammatory drug
po By mouth (per os)
PT Prothrombin time
PTT Partial thromboplastin time
q Every
qd Every day, daily
qid Four times a day
qod Every other day
RBC Red blood cell
SC Subcutaneous
sec Second
SGOT See AST
SGPT See ALT
STD Sexually transmitted disease
TB Tuberculosis
tid Three times a day
TSH Thyroid stimulating hormone
U Unit
UA Urine analysis
WBC White blood cell, white blood count
WHO World Health Organization
Part I
The Principles of Family Medicine
Family Medicine: Fifty Years of Caring
for America 1
John W. Saultz, Robert B. Taylor, and Paul M. Paulman
Contents
A Short History of the Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Family Medicine as a Social Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Family Medicine as a Defense of General Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Family Medicine as a Reform Movement Within Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Evolution of Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Family Medicine in the United States in 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Family Medicine and General Practice Around the World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Academic Principles of Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Comprehensiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Care Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Contextual Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Current Challenges and Future Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
The Unsustainable Cost of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Commercialization of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Sustaining Family Medicine as a Desirable Specialty Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
J. W. Saultz (*)
Department of Family Medicine, Oregon Health and
Science University, Portland, OR, USA
e-mail: saultz@ohsu.edu
R. B. Taylor
Department of Family and Community Medicine, Eastern
Virginia Medical School, Norfolk, VA, USA
Oregon Health Science University, Portland, OR, USA
e-mail: taylorr@ohsu.edu
P. M. Paulman
Department of Family Medicine, University of Nebraska
e-mail: ppaulman@unmc.edu
© Springer Nature Switzerland AG 2022 3

P. M. Paulman et al. (eds.), Family Medicine,
https://doi.org/10.1007/978-3-030-54441-6_159
4 J. W. Saultz et al.
Information Technology and the Tension Between Personal Care and

Population Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Globalization and Global Health Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Caring for the World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Important Internet Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
In its early years, the specialty of family medicine was being challenged. Rapid population growth
had originated within the lifetimes of its practi- and accelerating medical specialization following
tioners. As family medicine celebrates its 50th World War II precipitated a decline in access to
anniversary, the founding generation has retired, primary health care at the community level in the
and today’s family physicians (FPs) are providing United States. Although a handful of general prac-
care in a very different world. Few are in solo tice residencies were established in the 1950s,
practice. Many are employed in integrated health generalist training was inadequate in both quality
systems. and most use electronic information sys- and capacity. In response, the American public
tems to document care and communicate with and farsighted health policy planners decried the
patients. Since its beginning in 1969, family med- fragmentation of American medicine and called
icine has become one of medicine’s largest and for the creation of a physician who specialized
most successful specialties. And yet many of its in primary health care. Three influential reports,
current members are unfamiliar with the inspiring all published in 1966, made the case for what
story of how the specialty began. For this reason, eventually became family medicine. These
this book begins with an overview of the reports have historically been referred to by the
specialty’s origin, evolution, and current status. names of their chairmen: the Folsom report, the
The goal of this chapter is not simply to preserve Millis report, and the Willard report.
a record of the past but also to explain how family The Folsom report was a report of a national
medicine came to be the way it is, to delineate commission on community health services and
lessons learned by its first two generations of was sponsored by the American Public Health
leaders, and to provide a context for building the Association and the National Health Council [1].
discipline’s future. This commission’s 4-year investigation produced
14 recommendations. The most pertinent to the
evolving specialty of family practice was a task
A Short History of the Specialty force report entitled The Changing Role of the
Personal Physician, which concluded that all
Family medicine in the United States evolved Americans should have “personal physicians” to
from general practice, which was the dominant ensure the integration and continuity of their
force in health care until the mid-twentieth medical services. The report emphasized the
century. The story of how this happened can be importance of preventive medicine, the use of
told in at least three ways, and each of these community resources, and the importance of
creation stories offers insight into the specialty’s caring for the patient in a continuity context.
traditions and values. The second report was from the Citizens’ Com-
mission on Graduate Medical Education, which
was sponsored by the American Medical Associa-
Family Medicine as a Social Movement tion [2]. This commission focused on graduate
medical education. Specifically, it suggested that
Family practice arose as a specialty during the “primary physicians” be trained to replace the
1960s – the time of the Vietnam War, the civil dwindling number of general practitioners. The
rights movement, and widespread social unrest – a Millis report specifically addressed the importance
time not unlike today when the wisdom of experts of comprehensive clinical skills, continuity of care,
1 Family Medicine: Fifty Years of Caring for America 5
coordination of services, and preventive services to Declining numbers threatened the ability of gen-
be provided by these new primary physicians. eral practitioners to obtain and retain hospital
The third report was from the Committee on privileges and undermined their prestige and
Education for Family Practice, which was spon- political influence within the profession. While
sored by the Council on Medical Education of the first creation story is fundamentally a story
the American Medical Association (AMA) and of social activism, there is also a side of the story
was charged to review AMA policy regarding that was about preserving a way of life for those
the future of general practice [3]. The Willard practicing in community.
report specifically called for a new kind of spe- Four early decisions helped shape the future of
cialist in family practice and even specified the the new specialty, and all were about enhancing
outline of a training program for “family physi- the quality and prestige of the field. A specialty
cians.” It also recommended the establishment certifying board – the American Board of Family
of a certifying board in family practice. Practice – was created in 1969. Three-year
Dr. Willard was the dean of medicine at the residency training programs were established in
University of Kentucky. At that time, the chair- contrast to the prior norm of a single year of
man of the department of medicine at that med- internship for general practitioners. Mandatory
ical school was Edmund Pellegrino. Because of recertification was pioneered by the ABFP, and
his experience with general practice residents in all US board-certified family physicians still must
the 1950s, Dr. Pellegrino chose to appoint two undergo periodic recertification. Most other spe-
general practitioners to the full-time faculty in cialties have since established similar require-
the department of medicine [4]. One of these ments. Finally, mandatory continuing medical
individuals – Nicholas J. Pisacano – was an education was required by both the American
idealistic and scholarly general practitioner who Academy of Family Physicians (AAFP) and the
was already one of the most outspoken advo- American Board of Family Practice.
cates for certification in the field. When the The new specialty began with 15 residency
American Board of Family Practice ultimately training programs, most converted from the few
achieved recognition as a certified specialty existing general practice programs. Federal grant
board, it was Dr. Pisacano who became its programs supported new departments of family
founding executive director. medicine in medical schools, and clinical depart-
With the support of the American Academy ments of family practice were formed in commu-
of General Practice (AAGP) and US general nity hospitals across America. From 1969 until
practitioners, family practice became the 20th today, the family medicine movement has contin-
American medical specialty in 1969. The story ued to gain momentum, with solid gains in student
of these three influential reports provides the recruitment, more residents in training, increased
first of family medicine’s creation stories – a numbers of board-certified FPs in practice, and
story focused on needs identified by public family physicians in leadership positions in clini-
policy-makers during a time of social unrest cal medicine and academia.
and reform.
Family Medicine as a Reform

Family Medicine as a Defense Movement Within Medicine
of General Practice
The birth of family practice can also be viewed
Family medicine also arose as a political and as an intellectual and philosophical reform of
professional defense of the general practitioner. medicine as a profession. The new specialty
Leaders in the American Academy of General faced extensive opposition from both organized
Practice (AAGP) were alarmed as early as the medicine and from the academic world of the
1940s by the declining number of medical stu- medical schools. This criticism was usually
dents choosing to enter general practice [5]. based on the argument that there was no unique
field of knowledge constituting family practice. The Evolution of Family Medicine

Instead, the knowledge, skills, and attitudes of a
family physician were felt to be derived from the At its birth, the specialty’s name was family prac-
fields of surgery, obstetrics and gynecology, tice in large measure as a tribute to its roots in
pediatrics, and so on. The early residencies were general practice. The term family medicine was
largely dependent on educational rotations with used to refer to the academic discipline as some-
each of these specialties, and this no doubt gave thing separate from the clinical specialty. Family
credence to this claim. Since medical school physicians in the 1970s still largely practiced in
departments generally reflect an academic disci- solo practices and small groups with one another.
pline instead of a practice specialty, the perceived Most were self-employed small business owners,
lack of an intellectual foundation to the field and the care was delivered in one-on-one relation-
severely hampered the establishment of depart- ships between the doctor and patient. By the
ments of family medicine in medical schools. 1980s, a growing number of family physicians
Departments were established most quickly in were in group practices; solo practice was becom-
publicly funded institutions, where political pres- ing rare as the administrative complexities of
sure from state legislatures was brought to bear to medicine made economies of scale and shared
effect these changes. A few private universities administrative resources more efficient. The
continue to hold out to this day. 1980s also brought increasing scrutiny to the
But there was a much more fundamental rea- high cost of medical care and insurance compa-
son for the opposition. After the Flexner report nies evolved from simply paying claims to mount-
of 1910, American medicine had evolved into a ing efforts to manage care. This inevitably
biologic science focused on better understanding resulted in attempts to limit specialty referrals,
the mechanisms by which diseases arise and are emergency department visits, and hospitalizations
treated. On the one hand, this model can be and the responsibility to manage cost often fell
credited with astonishing advances in medical to those practicing primary care. The 1990s
science and resulting improvements in the length witnessed a substantial increase in medical stu-
and quality of life over the twentieth century. dent interest in family medicine and, for a while, it
But this model was also directly responsible for seemed that the imbalance between primary and
a loss of patient-centeredness in favor of a specialty care was being corrected. Family physi-
disease-oriented approach to care [6]. From its cians even began to play important roles in the
very beginning, family medicine was a counter- management of health plans and medical groups.
culture movement pushing back on these trends Unfortunately, these gains were short lived. By
– and counterculture movements threaten the the early 2000s, it became clear that the adminis-
status quo. A series of essays entitled The Intel- trative complexity of the managed care era had
lectual Basis of Family Practice was published failed to adequately control health-care inflation.
by G. Gayle Stephens during family medicine’s The insurance system moved away from
first decade [7]. Stephens’ work became a rally- structures based on primary care utilization
ing call for many of the first generation of family management and began passing increasing costs
medicine residents. Family medicine has cer- to patients as out-of-pocket deductibles and
tainly been a social movement about making copayments. Primary care again fell in prestige
care available to the American people, and its and student interest declined. In 2002, the spe-
founding generation of physicians was certainly cialty of family medicine conducted a strategic
interested in preserving and improving general planning process call the Future of Family
practice. But many others entered the field to Medicine project (FFM) [8]. The outcome of this
change American medicine intellectually by process was documented in six reports, all
incorporating social, behavioral, and population published in the discipline’s new research journal
scientific methods into a world dominated by the Annals of Family Medicine in 2004. One rec-
biology and reductionism. ommendation from this process was that the
specialty name should change from family prac- also embraced the need for improvements in pop-
tice to family medicine and organizations like the ulation outcomes as measured by electronic health
American Board of Family Medicine changed data, with accountability lying with practice orga-
their names accordingly. The most important rec- nizations. In 2014, another specialty-wide strate-
ommendations of the FFM all related to a pro- gic planning effort was undertaken. This project,
posed new model of clinical care that eventually called Family Medicine for America’s Health,
came to be known as the patient-centered medical eventually recommended an expansion of the
home (PCMH) [9]. At its heart, the PCMH called PCMH model to fully integrate mental health
for an evolution from the one-on-one doctor and population health into the primary care
patient relationship to a notion of team-based system [10]. Today, practices throughout the
care in which family medicine practices were country are struggling to make these recommen-
asked to create and empower teams of providers dations a reality. But this enhanced PCMH model
to share responsibility for their patients. Systems adds even more costs to the primary care system,
were devised to certify practices as PCMHs and, and it remains to be seen if reimbursement reform
by the end of the decade, electronic information will support such systems in the long term.
and communication systems became require- Throughout its history, family medicine has
ments for PCMH designation. Although some of struggled to attract a sufficient number of new
the initial cost of these electronic health records family physicians even as more and more respon-
was supported by the federal government, their sibility has fallen to the primary care system.
ongoing cost led to practice expenses that could By 2020, the number of medical schools and the
not easily be borne by the revenues generated number of graduating medical students have
from primary care practice alone. This further grown substantially, but family medicine still
catalyzed consolidation of practices into larger struggles with the inescapable reality that there
and larger groups and, in many cases, to practice are not enough family physicians to care for the
networks owned and supported by hospital-based American people. So a gap widens between fam-
systems. ily medicine ideals and the pressing realities of
Following the great recession of 2008, cost family physicians’ day to day work.
containment efforts had again failed to limit In 1987 Pellegrino [11] commented: “The birth
continuing increases in health-care spending and of Family Practice two decades ago, and its devel-
large delivery systems managed to increase reve- opment as a genuine specialty within the bodies of
nues even as the overall economy lagged. But as both medical practice and academia is surely one
cost pressure increased on these systems, the need of the most remarkable stories in contemporary
for larger and more effective primary care systems medical history.” Now 50 years old, the specialty
became apparent. While large delivery systems remains one of the shining accomplishments of
supported growth in primary care, they generally twentieth-century medicine. Family medicine was
opposed increasing reimbursement for these ser- born in an era of social change to protect and
vices, preferring instead to move hospital and professionalize general practice and to reform
specialty profits into primary care investments. American medicine. The need for the discipline
Under such conditions, more and more family has never been more apparent than it is today.
physicians became employees of large health sys-
tems and medicine evolved from loosely linked
small businesses to influential and sometimes Family Medicine in the United States
monopolistic corporate entities. in 2020
As the decade of the 2010s ends, family med-
icine again stands at crossroads. On the one hand, In 2018, there were 985,000 licensed physicians
its values remain rooted in the one-on-one doctor- in the United States [12] of which 139,000
patient relationship with personal accountability were professionally active FPs [13]. There are
resting on the physician. But the discipline has 131,000 members of the AAFP [14] and 92,000
diplomates certified by the ABFM [15]. The spe- of National Colleges, Academies, and Academic
cialty had 679 accredited residency programs with Associations of General Practitioners/Family
13,924 residents in training during the 2019–2020 Physicians (WONCA). More commonly known
academic years making it the largest specialty as the World Organization of Family Doctors,
in terms of programs and the second largest in WONCA is comprised of 118 member organiza-
terms of resident enrollment [16]. Family medi- tions in 131 countries, with membership of about
cine is well-established in nearly all of the nation’s 500,000 family doctors worldwide [20]. WONCA
medical schools, and there are required courses advocates for family medicine internationally and
and established research programs throughout hosts regional meetings in seven regions around
the country. In 2015, 6738 faculty members in the world. Some countries have retained the title
134 academic departments of family medicine general practitioner while others have adopted the
published 3002 peer-reviewed scientific papers name family physician, but around the world, the
and federal research funding supported over half core principles of the discipline are pretty much
of this work [17]. the same. Much of WONCA’s international work
The specialty has been undeniably successful has referenced the Alma-Ata Declaration of 1978
as measured by these accomplishments. And yet which was adopted by the World Health Organi-
there are concerning trends. Most of what is zation and defines the international importance of
known about the clinical work of family physi- primary care. Alma-Ata stands as one of the most
cians is based on studies of ABFM diplomates, important statements of public health principle of
admittedly a subset of all family physicians. But the twentieth century, and this work has catalyzed
evidence from the ABFM suggests steep declines the development of family medicine in most of the
in the number of family physicians delivering countries in the world with special emphasis on
maternity care, caring for hospitalized patients, developing countries.
and caring for children, and these changes have The nature of day-by-day practice in family
begun to impact the availability of basic health medicine varies from country to country.
services, particularly in rural and under-served In some areas, such as the United States and
communities that are most likely to be served by Canada, family physicians often have an active
family physicians [18]. Burnout and career dissat- role in hospital care. In other settings, such as in
isfaction are major problems among physicians the United Kingdom and Latin America, family
overall, and studies estimate that over half of the medicine is chiefly office-based, often supple-
nation’s family physicians describe themselves as mented by home care. But family physician and
burned out. Although there has been rapid growth general practitioners around the globe deliver care
in the number of residency programs, family med- based on shared academic principles.
icine attracted only 12.6% of US allopathic and
osteopathic medical school seniors in 2018 [19].
Even more concerning, striking racial and geo- Academic Principles of Family
graphic disparities in health status have widened Medicine
even though more Americans than ever have
health insurance coverage. As proud as family The official definition of family medicine is:
physicians justifiably are, the true promise of Family medicine is the medical specialty which
family medicine remains unachieved in America. provides continuing, comprehensive health care
for the individual and family. It is a specialty in
breadth that integrates the biological, clinical and
behavioral sciences. The scope of family medicine
Family Medicine and General Practice encompasses all ages, both sexes, each organ
Around the World system and every disease entity. [21]
The international group uniting family medicine This definition focuses on family medicine as a
and general practice is the World Organization specialty of medicine and not on family medicine
as an academic discipline. From the specialty’s while other physician groups (general internal
early days, some authors have considered family medicine and general pediatrics) and other pro-
medicine to be the name of the academic discipline fessionals (nurse practitioners and physician
on which the specialty is based and have discrim- assistants) deliver primary care, the study of how
inated between an academic discipline and a med- primary care is optimized has largely become the
ical specialty. Now that the specialty name is also domain of scholars in family medicine. Impor-
family medicine, the distinction might be a moot tantly, the term “scholars of family medicine” is
point. Nevertheless, the specialty’s 50-year history not limited to family physicians. Departments of
has produced a body of scholarly work that is family medicine now contain faculty members
uncontestably unique and important, and this with backgrounds in over a dozen fields including
body of work represents an academically rigorous the social and behavioral sciences, health eco-
intellectual field. Although this chapter will not nomics, public health, statistics, nursing, and
attempt to list them all (in fear of offending by communications in addition to medicine.
omission), there are currently at least 20 English The scholarly development of family medicine
language family medicine journals worldwide as is exemplified by the work of Barbara Starfield,
well as hundreds of books and thousands of schol- a pediatrician and health services researcher who
arly publications in clinical and health policy spent her career studying the core elements of
journals [22]. So, while the earliest scholarship in primary care from a health policy perspective [25,
the field was focused on describing what family 26]. Starfield first demonstrated that primary care is
physicians do, the field has now broadened to the strongly associated with better health outcomes
study of how practice outcomes can be optimized. and lower health costs after examining data from
Although there continues to be considerable debate nations around the world. These same associations
about the precise definition and content of family were present when her team examined data com-
medicine as an area of study, family medicine as an paring American states and local communities.
academic field is best defined as the study of how Starfield then became interested in distilling pri-
best to deliver efficient and affordable primary care mary care to its core elements as a way of measur-
to populations and communities [23]. ing its effectiveness in improving population health
Primary care is a term derived from the public outcomes. Based on this work as well as the work
health literature and refers to first-contact health of many others, the academic principles central to
services delivered at the community level, in con- primary care’s positive impact on public health
trast to secondary care (care delivered by specialty constitute family medicine’s core academic princi-
consultants and in community hospitals) and ter- ples. These are access, continuity, comprehensive-
tiary care (care delivered in specialized academic ness, care coordination, and contextual care [23].
settings). The most uniformly accepted definition
of primary care was published after extensive
study by the National Academy of Sciences Access
Institute of Medicine in 1996:
Most of the care delivered by family physicians is
Primary care is the provision of integrated, first-contact care with patients who choose when
accessible health care services by clinicians who and how to access that care as opposed to being
are accountable for addressing a large majority of
referred by another clinician. Access to care
personal health care needs, developing a sustained
partnership with patients, and practicing in the encompasses the study of how patients make
context of family and community. [24] these choices. Family physicians need to under-
stand how barriers to access limit the patient’s
Nearly all family physicians provide primary care, ability to get the care he or she needs. Also impor-
but historically they have also provided services tant, however, is the study of why some patients
such as maternity and hospital care that would overuse health care and how to manage and mod-
be characterized as secondary care. Furthermore, ify access. Understanding access to care includes
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Se soutavi seljässä delfiinein, sen lempeä lainehet laulaa,
ja kanssa Vellamon impyein, hän aikojen aalloilla kaulaa. Siis
viritä virtesi, nuori mies! Voi, pian se riittyvi rinnan lies, ja
vanhuus jo sauvoilla hoippuen saa. Suo kantelos kajahtaa!
Hiihtäjän virsiä
Hiihtäjän hyräily.
Hyvä on hiihtäjän hiihdellä, kun hanki on hohtava alla, kun

taivas kirkasna kaareutuu — mut hauskempi hiihtää, kun
ruskavi puu tuul' ulvovi, polku on ummessa ja tuisku on
taivahalla.
Hyvä on hiihtäjän hiihdellä, kun ystävä häll' on myötä, kun

latu on aukaistu edessään — mut parempi hiihdellä yksinään,
tiens' itse aukaista itselleen ja yksin uhmata yötä.
Hyvä on hiihtäjän hiihdellä, kun tietty on matkan määrä, kun

liesi viittovi lämpöinen, — mut sorjempi, uljaampi hiihtää sen,
joka outoja onnen vaiheita käy eikä tiedä, miss' oikea, väärä.
Ja hyvä on hiihtäjän hiihdellä, kun riemu on rinnassansa,

kun toivo säihkyvi soihtuna yöss' — mut käypä se laatuun
hiihtää myös hiki otsalla, suurissa suruissa ja kuolema
kupeellansa.
1898.
Se Herra, jota ma palvelen
Se Herra, jota ma palvelen, se ei ole Herra teidän, ei tunne

se kirkkoja, munkkeja, ei kuule se messuja heidän. Se Herra
se asuvi korvessa ja hän on korven Herra. Hänet kasvoista
kasvoihin siellä ma näin, kun metsiä hiihdin kerran.
Sinä hiihdät päivän ja hiihdät kaks' ja yksin jo olevas' luulet

ja olevas' herra jo metsän ja maan — niin kaukaa sa kohinan
kuulet ja humisten taipuvi metsän puut ja kalliot haljeten
huhuu. Oi, lankea maahan sa polvillesi Se on Herrasi ääni, mi
puhuu.
Hän tuli ja nosti mun jalkeillen mua katsoen silmäteriin:

"Sinä siiskö se kaipaat metsähän? Mikä miehen on mennyt
veriin? Hyvä! Korpi on asua annettu ja suksi on hiihtää suotu,
mut muistaos ihminen metsässäi, sa että vaan olet luotu.
Ota viita, viljele, kesytä maa, ota vesi ja verkkosi heitä,

pane paulat, aseta ansapuut ja sangat sammalin peitä, mut
lähde laululla metsähän, älä veikaten vettä souda, vaan hyviä
virsiä hyreksien sinä eräsi viidasta nouda!
Näät mun on meri ja mun on maa ja mun on metsän valta.

Ja vaikka sa kylästä väistyitkin, et väisty mun voimani alta.
Mut että sa ihminen tietäisit, mitä metsien Herra vaatii, niin
kuuntele korvin avoin nyt, kun sulle hän lakinsa laatii:
Ei riitä ne ripit, ei mittapuut, kun ahmaa aalto syvä. Ja vasta
kun paha sa olla voit, niin voit sinä olla hyvä. Ole hyvä kuin
laps', ole syvä kuin mies, ole voimakas niinkuin vuori, min
povessa palkeet ja vasarat käy, mut päällä on kivinen kuori.
Pidä pääsi pystyssä metsämies, sinä maailman silmäterä!

Mut jos sinä korpehen kaadutkin, älä kantoja syyksesi kerää,
kukin päähänsä silmää kaksi sai, kukin oman on onnensa
seppä. Sitä onneas et sinä antaa saa, jos kuivuis' kuu ja
leppä.
Pyri aina ja ylemmä, joutsimies,

kuin siipesi täysin kantaa.
Mies kasvavi kanssa tahtonsa
ja tahto voimia antaa.
Ken täällä ei kurota kuusehen,
ei kapsahda katajaankaan.
Ken täällä ei tavota taivaihin,
ei pääse se päälle maankaan.
Näe unia suuria, unten mies!

Uni puoli on todellisuutta.
Uni kulkevi edellä kyntäjän
ja viittovi uraa uutta.
Vain yksi valta on metsässä:
On mies ja miehen usko!
Sitä kuulevi pedot ja metsän puut
ja aika ja aamurusko.
Mut yksi on Herra herrallakin,

jota pääse et palvelemasta.
Näät siinä, miss' alkavi velvollisuus,
siin alkavi elämä vasta.
Ja sen on meri ja sen on maa
ja sen on metsän valta
ja vaikka sa kylästä väistytkin,
et väisty sen voiman alta.
Ja vaikka sa korpea hiihtäisit kuin hirvi ja jalopeura, se

Herra sun kulkevi kupeellas, se kantapäilläsi seuraa, se
kurkistaa joka kuusesta ja pensaista, puista se puhuu, ja
ympäri nuotios' yöllisen käy ääni, mi käskee ja huhuu,
Ja vaikka sa vuorille kiipeisit kuin kotka, mi saalista noutaa,

se pilvenä piirtävi vierelläs', se sotkana järvet soutaa, se
kasvaa ja paisuu ja karttuu vaan, sadan virstan on saappahat
hällä, ja vuortenkin huipuilta huutavi se ukkosen jylinällä:
Ja vaikka sun ois koko mahti maan, veen kunnia, vuorten

kulta, niin sentään ma ropohon viimeiseen olen veroni vaativa
sulta. Minä taivahan rantoja taivallan, käyn Otavan olkapäitä.
Ja jos sinä tahdot korpehen, niin laulele lakeja näitä!"
Pois kulki mun Herrani korvessa.

Taas kaikki, kaikk' oli hiljaa,
Mut uudet tuulet mun sydämmessäin
ne tuutivat uutta viljaa.
Ja taasen ma tartuin sauvahain
ja sukseni sujutin jälleen.
Mut usein, niin usein korvessain
olen saanut ma huoata tälleen:
"Oi, ethän sa kasvojas' käännä pois, sinä Herra, ystävä,

veikko, jos olikin suuri sun korpesi ja hiihtäjä jos oli heikko.
Sinä käskithän ylemmä lentämään kuin siivet heikot kantaa.
Mies kasvavi kanssa tahtonsa ja tahto voimia antaa."
1898.
Laulu onnesta.
Kell' onni on, se onnen kätkeköön, kell' aarre on, se aarteen

peittäköön, ja olkoon onnellinen onnestaan ja rikas
riemustansa yksin vaan.
Ei onni kärsi katseit' ihmisten. Kell' onni on, se käyköön

korpehen ja eläköhön hiljaa, hiljaa vaan ja hiljaa iloitkohon
onnestaan.
1898
Orvon laulu.
En apua saanut, en apua saanut, kun nuorna ma äidistä

orvoksi jäin, kun kuljin ma kerjäten mieron teillä ja anelin
rakkautta kyyneleillä, en apua saanut ja yö oli ainoa ystäväin.
En apua saanut, en apua saanut, kun taistelin, eksyin ja

epäilin, kun epäilin muita ja itseäni ja sylkytin sairasta
sydäntäni, en apua saanut ja yksin ma kuljin ja kamppailin.
En apua saanut, en apua saanut, en olisi paljoa pyytänyt,
vain vähäsen lämpöä ympäriltä, vain hiukan hienoutta
ystäviltä, — kun oisin saanut, niin ehkä paljon ois paremmin
nyt.
En apua saanut, en apua saanut, nyt sitä en pyydä, en

kaipaakaan. Minä elelen kaukana korvessani ja kehrään öisiä
aatteitani ja mitä ma mietin, sen tietävi huojuvat hongat vaan,
En apua saanut, en apua saanut, mut joku jos heltyis' mun

laulustain, ja käsi jos poskelle kohois' kellä, ja miettimään
kävis' mieli hellä, niin hälle, hälle
sois' laulu hiihtäjän ladulta ain'.
Jos voisin laulaa kuin lintu laulaa, tai lailla honkien huoju
vain kun metsän äänillä puhua voisin, kun purona pulppuisin,
käkenä soisin, niin näinpä, näinpä sois' laulu hiihtäjän ladulta
ain':
"Oi, älkää ihmiset ilotella, jos orpo tiellänne lankeaa, ei ole

orvolla äidin kättä, vaan yksin hoippuen, ystävättä, hän etsii,
eksyy ja yksin syynsä hän sovittaa!"
En apua saanut, en itse saanut, mut näin jos kuiskisi

kuusipuut ja käsi kun poskelle kohois' kellä ja miettimään
kävis' mieli hellä, niin ehkä, ehkä, mit' en ma saanut, sen saisi
muut.
1899.
Iltatunnelma.
Mun päiväni ammoin mennyt on,

yhä mailla on illan rusko.
Mit' tää on? Miks' ei joudu jo yö,
kun hiljaa, hiljaa niin sydän lyö
ja kuollut on kunto ja usko?
Kas, taivahat kuinka ne loimottaa!

Joko tullut on tuomion päivä?
Tää heijastus silmäni huikaisee.
Tuhat kertaa mieluummin pimeyteen,
missä ympär' on huuru ja häivä!
Olin minäkin nuori ja onnellinen.

Näin unta ma kesästä kerta.
Kas, hämärän neittä ma lempiä sain,
ma hirveä hiihdin, mi pakeni vain —
te nähkää hangilla verta.
Veri punainen ratkesi rinnastain.

Veit paljon sa tyttöni multa.
Ja vereni nuori ja lämpöinen
se kirjoja kirjoitti hangillen:
sinä siunattu, kiitetty, kulta!
Runoruusut rintani raadellun

te rastitte hiihtäjän matkaa
yli vuorien, yli laaksojen,
ohi murheen ja onnelan ovien —
Mihin? Tee ei miel' juuri jatkaa.
On päivä jo ammoin laskenut,
yhä poissa on hiihtäjän rauha,
käs' vaipuvi, henkeni herpoutuu.
Oi, eikö jo kohoa kalpea kuu
ja lasken yöhyt lauha?
1898.
Hautalaulu.
Levoton on virta ja vierivä laine,

meri yksin suuri ja meri ihanainen.
Nuku virta helmassa meren.
Tuuli se kulkee ja lentävi lehti.

Onnellinen on se, ken laaksohon ehti.
Nuku lehti helmassa laakson.
Päivä kun nousee, niin sammuvi tähti.

Ei se ijäks' sammu, ken elämästä lähti.
Nuku tähti helmassa päivän.
1898.
Oi, varjele Herra mun järkeäin —

Oi, varjele Herra mun järkeäin, mua varjele hullun yöstä,
mua kurita, mut älä anna mun näin elävänä hautahan syöstä.
Mun pääni on niin sairas, mun päiväni levoton ja yö kun
musta joutuu, niin poissa mun uneni on. Herra, varjele järkeni
valo!
Minä kuulen ääniä kummia,

joit' eivät toiset kuule.
Ja vaikka ma syntiä paljon tein,
mua paatuneeks' älä luule.
Ei aina ole huono, ken täällä lankeaa,
voi olla jalka heikko ja kivinen olla maa.
Herra, varjele järkeni valo!
Älä usko, mit' ihmiset sanovat, älä kysele heiltä mua, mut
kysy mun kuolleelta äidiltään, joka lienevi lähellä sua. Mua
ihmiset ei nähneet, ne näki mun varjoni vain, minä itse
kaukana kuljin ja kaukaa viestit sain. Herra, varjele järkeni
valo!
Sain viestit mailta vierailta,

joit' eivät toiset tunne.
Minä nään vain sumua silmissäin,
ma vaikka katson kunne.
En erota ma muuta kuin kasvot äityein.
Oi, äiti, äiti, äiti, oi ota mun sydämein!
Minä olin hänen kultasilmänsä

ja hän mua hemmotteli.
Hän rukoili mun puolestain
niin kauan kuin hän eli.
Oi, ethän, ethän, äiti, mua heitä vieläkään.
Kun sua vain ma muistan, niin itken yhtenään.
Kas itku syömen puhdistaa — Oi, kiitos, kiitos Herran, viel'

että voin ma itkeä — kai anteeks' annat kerran. Oi, Herra,
Herra, Herra, ota multa kaikki muu, ota leipä, laulun lahja, tai
sulje mullalla suu, mutta varjele järkeni valo!
1898.
Kuoleman renkinä.
Kuljin ma kuoleman peltoja pitkin,

kuolema kynti ja minä itse itkin.
"Tule mies rengiksi!" kuolema huusi —

"Saat palan peltoa ja laudanpäätä kuusi".
"Tulen minä rengiksi," huusin ma vastaan.

Tottahan Tuonela hoitavi lastaan.
Siitä asti kynnän mä kuoleman sarkaa —

viikot ne vierii ja elonhetket karkaa.
Ystävä on kaukana ja sydämeni jäässä —

Herra, koska seison ma sarkani päässä?
1898.
Rauhattoman rukous.
Minä tääll' olen vieras, vieras vaan, olen ollut alusta

saakka, ovat outoja minulle laaksot maan ja outo on elämän
taakka. Minä kuljen ja katson kummastuin joka puuta ja joka
kukkaa, minä kuljen kumpuja itkusuin ja itken ihmisrukkaa.
Me soudamme haahta haurasta, min ympäri aallot pauhaa;

me kuljemme suurta korpea ja emme löydä rauhaa. Tiet
riidellen ristivät toisiaan ja ystävä toista pettää. Mikä riemu se
koskaan päällä maan on päättynyt kyynelettä?
Mikä laps' se on matkalle lähtenyt, joka joutunut tääll' ei

harhaan? Mikä hyvä se täällä on hyötynyt, joka kuollut ei liian
varhaan? Kun ystävän parhaan sa kohtasit jo aika on hyvästi
heittää. Ketä hellimmin tänään sa rakastit, sen huomenna
hauta peittää.
Oi, joutuos kirkkahin joulu-yö, oi, syntyös sydämihin, oi,

syntyös syömehen jokaiseen, joka tutkivi: mistä? mihin? Oi,
syntyös rauha mun rintaani kuin syntyi seimehen lapsi, sinä
rauhani nuori ja naurusuu, sinä kukkani kultahapsi.
Ja kilvan kulkisi kumartamaan sua turhan tietoni aatteet,

kuka kullat tois, mikä mirhamit, mikä päärlyt ja
purppuravaatteet, Mun henkeni tietäjät harmaapäät erämaita
ne etsien käypi, mut taivas on tumma ja tähdetön ja yö yhä
hämärtäypi.
Minä lapsena vanhaksi vanhenin.

En nuor' ole koskaan ollut.
Toki kerran ma keväästä haaveilin,
mut haavehet nuo oli hullut.
Olen väsynyt lauluni valheeseen,
Herra, tee minut lapseksi jälleen!
Minä tahdon soittoni särkyneen
viedä suurelle virittäjälleen.
1898.
Ja vuodet ne käy yhä vaikeammiks'.
Ja vuodet ne käy yhä vaikeammiks' ja haaveet ne käy yhä

haikeammiks', ne polttaa, ne hehkuu, ne halaa. Joka ilta ma
mietin: Kai huominen uus' tuo lohdun ja loppuvi
rauhattomuus! Yö loppuu, mut murheet ne palaa.
Ne tulevat niinkuin kotihin, ne tuovat uusia vieraitakin, jotka

nimeltä tunnen ma juuri. Se murhe, mi eilen mun murtaa oli,
suli hymyks', kun tänään suurempi tuli — koska tulee se
suurin, se suurin?
Koska saavut sa tuskani korkein, sinä maailman valtias

mahtavin, jota lapsesta saakka ma uotin, jota vapisin öisin mä
vuoteellani, jonk' katsehen tunsin ma kasvoillani, kun hetkeksi
onneeni luotin?
Sun edessäs' tahdon ma polvistua, mut silmihin katsoa

tahdon ma sua ja sanoa: Henkeni annan! mut mieltäni nuorta
en milloinkaan. Se tuskassa tulta iskevi vaan, sen kanssani
hautahan kannan.
1899.
Mua pelottaa.
mua pelottaa, Mua pelottaa, mua pelottaa tämä erämaa,

mua pelottaa nämä ihmiset, nämä katsehet niin oudot ja
kylmät ja kylläiset.
En tunne ma muita, en itseäin.

Miten outojen joukkoon ma jouduinkin näin?
Toki jossakin muualla parempi ois'?
Kun huoata vois'
tai nukkua, nukkua nuorena pois!
Oi, vieraita oomme me ihmiset

kuin eri tähdillä syntynehet,
kuka kotoisin kuuhuen helmasta on,
kuka auringon,
kuka aivan, aivan on koditon.
Minä lapsonen koditon laaksoissa maan, minä hankia

hiihdän ja harhailen vaan, minä sydäntä etsin, mi sylkähtäis',
joka luokseni jäis', yö vaikka mun ympäri hämärtäis'.
Minä etsin suojoa itseltäin ja omilta hulluilta mietteiltäin;

mua pelottaa nämä ihmiset, nämä katsehet, mut enin mun
syömeni syvyydet.
1899.
Sydämeni talvi.
Talvella lauluja tehdä ei, talvella tehdään työtä, talvella

tuvassa istutaan, iltoja pitkiä iloitaan, talvella paljon on yötä.
Talvella talossa kiirettä ei, talvell' on pitkät puhteet, talvella

hiljaa haastellaan, lauluja vanhoja lauletaan, kuulu ei isännän
nuhteet.
Huurtehessa on honkapuut,
hyyteessä ikkunalaudat.
Ihmiset takkahan tuijottaa,
hiljaa hiiliä liikuttaa —
liikkuvi muistojen haudat.
Talvella murheita muisteta ei, talvella paljon on lunta,

muistoja kauniita katsellaan, riemuja vanhoja riemuitaan,
nähdähän kesästä unta.
Varpuset jäätyvät oksillaan, paksu on hanki maassa,

ihmiset kulkee ja askaroi — mielessä lintujen laulut soi,
kellojen kilke haassa.
Sisällä siintävi taivas sees, kukkivat kummut ja kedot,

laulavi leivot ja linnut muut — ulkona huojuvat honkapuut,
ulvovat metsien pedot.
Kuollut on usko ja rakkaus,
jäässä on ruusurukat.
Mutta kun illalla ikkunaan
loistavi kuu tahi tähti vaan,
kauniit on hallankin kukat.
Suru on siltoja siskojen,

sääli on hallan kukka.
Talvella toistansa säälitään,
itseään sekä ystäviään:
Ystävä, ystävä rukka!
Voi sinun hullua sydäntäs',

voi sinun hullua päätäsi
Tiedä en, kump' oli hullumpi,
hullut ne vaan oli kummatki,
tarvis ol' talven jäätäs'.
Tahdoitko toivoja toteuttaa,

näitkö sä onnesta unta?
Hangessa toivojen hauta lie.
Kaikilla meillä on yksi tie.
Talvella paljon on lunta.
1899.
Metsän kosija
(1898).
I.
Yksin hiihtäjä.
Minä hiihtelen hankia hiljakseen, jo aurinko maillehen

vaipuu, minun mieleni käy niin murheisaks', minun rintani
täyttää kaipuu. Latu vitkaan vie. Vai vääräkö lie? Niin pitkä on
yksin hiihtäjän tie.
Ja kuusien varjot ne tummentuu.

Minä annan aattehen luistaa.
Ja jos minä korpehen kaadun näin,
mua tokkokan kukaan muistaa?
Kylä kaukana on.
Nyt lepohon
ei aikaa vielä, ei aattelohon.
Olen hiihtänyt metsää, järveä ja rimpeä rannatonta, olen

laskenut rinteitä laaksojen ja kohonnut vuorta monta, ja
vuorien taa mun jäi kotomaa, mut voimani, voimani raukeaa.
Olen vierinyt maita ma vieraita ja ottanut merkkejä puista,

olen pyrkinyt, tahtonut, taistellut ja levänneeni en muista. Mut
määräni pää yhä loitoksi jää, Mun on niin kylmä, mua
väsyttää.
Ne nousevat lapsuusmuistot nuo, ne aukee maailmat

armaat, näen silmät mä äitini lempeän taas ja taattoni hapset
harmaat. Se vast' oli mies! Se taruja ties, kun joutui ilta ja
leimusi lies'.
Minä hiihtelen hankia hiljakseen

Tuul' hiljaa heittävi lunta.
Koti tuuliako ollut ja siskot ois'
vai oisko se ollut unta?
Miten korvessa näin
nyt yksinäin
minä hiihtäisin? Missä on ystäväin
Ei, enhän mä korpea hiihdäkään, minä hiihdänhän siskojen

kanssa, koti tuolla se vilkkuvi kultainen, tuli taasen on
takassansa, emo huolella käy, eikö lapsia näy, kun ilta jo
hangilla hämärtäy.
Älä murehdi turhia, äitini mun, me tullaan, tullaanhan kyllä,

me tulemme poskin niin lämpimin, meill' onhan villaista yllä, ja
jos kylmäksi jää sormi yks' tai tää, sun suukkosi kyllä sen
lämmittää.
Me hiihdämme alta ikkunan,

me katsomme salaa sisään:
Isä pitkää piippua polttelee,
emo takkahan halkoja lisää.
Hei, hip hip huraa!
kaikk' kerrassaan!
Ovi auki ja äidin helmahan vaan.
Ja kuusien varjot ne tummentuu, Tuul' hiljaa heittävi lunta.

Joko kotihin korpien hiihtäjä sai vai ollutko lie vain unta? Uni
tuskat vie. Päivä loppunut lie ja loppunut yksin hiihtäjän tie.
II.
Tellervo.
Ken siellä? Ken metsässä huhuilee? Kuka viidakon oksilla

vilkkaa? Ken heittävi huntua valkeaa ja puuhun piirtävi
pilkkaa? Se Tellervo on, tytär hongikon, opas metsien vieno ja
vallaton.
Hän saapuvi, hämärän iMpeni mun, luo sen, joka vaipui

varhain, hän tarttuvi kätehen tarmottoman, hänet ohjaten
ohitse harhain. Hän hymyilee ja hän lymyilee ja hän kuusikon
lehviltä kuiskailee:
"Mitä mietit sa poikanen poloinen, kun korpehen yöpyä

aiot? Ei vastahan Pohjolan pakkasta teho laulajan tieot, ei
taiot. Mut tulkosi näin minun jäljissäin, niin menemme
Metsolan linnoja päin."
Kas, Mielikki, metsien muori, on minun äitini kultainen,

kallis. Ei koskaan hän laulajan uupunehen näin hangelle
uinua sallis'. Näet lempeä on emo hongikon ja lempeä
honkien tytärkin on.
Ja vaikka sa et mua tunnekaan, sun tunsin jo kauvan,
kauvan. Kun hiljaa sa hyrisit hiihtäissäs', minä seurasin
sompoa sauvan. Ja hiljaa vain vaikka laulelit ain, minä kuulin
ja riemusin rinnassain.
Sua eivät ihmiset kuullehet,

mut metsä, metsä sun kuuli.
Minä laulua lemmin ja laulajaa
ja mulla on lämmin huuli.
Se suukkosen saa,
joka saavuttaa.
Tulet Metsolan tuolla jo pilkoittaa.
Ja Tellervo huntua huiskuttaa

ja laulaja kutsun kuulee.
Hän sauvahan tarttuu ja tavoittaa,
tytön kiini jo saaneensa luulee:
Suo suudelmasi
Mut kaukana, kas,
taas tyttö on petturi, peijakas.
Hän huntua heittää ja häilähtää, hän vierii ja väijyy ja

väikkyy, hän milloin vierellä virnakoi. taas milloin loitolla
läikkyy. Näet veitikka on tytär hongikon ja tanssi on luontoa
Tellervon.

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Family Medicine: Principles and

Practice Paul M. Paulman (Editor)

Principles and Practice of Stress Management Fourth

Principles and Practice of Hospital Medicine Sylvia C.

Social Emergency Medicine Principles and Practice 1st

Davidson’s Principles and Practice of Medicine, 24th

Social Emergency Medicine Principles and Practice

Primary Mathematics 3A Hoerst

DeLisa s Physical Medicine and Rehabilitation

Davidson's Principles and Practice of Medicine 23rd

With 198 figures and 357 Tables

Audrey A. Paulman Laeth S. Nasir

ISBN 978-3-030-54440-9 ISBN 978-3-030-54441-6 (eBook)

Family Medicine: Principles and Practice, eighth edition, is designed to

As we celebrate the publication of the 8th edition of Taylor’s Family Medicine:

1. To compile in a single textbook the fundamental principles of family

These objectives were pursued by seeking the advice and participation of

For the editors,

Part I The Principles of Family Medicine . . . . . . . . . . . . . . . . . . . . . 1

1 Family Medicine: Fifty Years of Caring for America . . . . . . 3

Part II Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Part III Pregnancy, Childbirth, and Postpartum Care . . . . . . . . . . 119

9 Preconception Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

10 Normal Pregnancy, Labor, and Delivery . . . . . . . . . . . . . . . . 137

Part IV Care of the Infant, Child, and Adolescent . . . . . . . . . . . . . 205

15 Genetic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Part V Care of the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

22 Selected Problems of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

26 Care of the Very Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Part VI Family Conflict and Violence . . . . . . . . . . . . . . . . . . . . . . . . . 375

27 Child Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

Part VII Behavioral and Psychiatric Problems . . . . . . . . . . . . . . . . 409

30 Managing Mentally Ill Patients in Primary Care . . . . . . . . . 411

Part VIII Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497

38 Common Allergic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 499

Part IX Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519

40 Epstein-Barr Virus Infection and Infectious

41 Viral Infections of the Respiratory Tract . . . . . . . . . . . . . . . . 527

45 Bacteremia and Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579

Part X Environmental and Occupational Health

48 Occupational Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625

Part XI Injury and Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651

50 Bites and Stings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653

Part XII Care of the Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703

54 Medical Problems of the Athlete . . . . . . . . . . . . . . . . . . . . . . . 705

55 Athletic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719

Part XIII Common Clinical Problems . . . . . . . . . . . . . . . . . . . . . . . . . 741

56 Care of the Patient with Obesity . . . . . . . . . . . . . . . . . . . . . . . 743

Part XIV Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873

71 Disorders of the Peripheral Nervous System . . . . . . . . . . . . . 937

Part XV The Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965

73 The Red Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967

Part XVI The Ear, Nose, and Throat . . . . . . . . . . . . . . . . . . . . . . . . . . 1005

76 Otitis Media and Externa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007

Part XVII The Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . 1041

85 Venous Thromboembolism . . . . . . . . . . . . . . . . . . . . . . . . . . . 1129

Part XVIII The Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167

87 Obstructive Airway Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 1169

Part XIX The Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1225