G. Gayle Stephens and Wrestling the Bear: A Perspective from the Keystone IV Conference

• Doctoring
• Family Medicine
• Family Physician
• Health Care Delivery
• Personal Physician
• Population Health
• Primary care
• Professionalism
• Social Justice

“I feel like a man who follows the carnival to wrestle the bear. The bear always wins but the man keeps coming, thinking he will do better next time.”¹

Gayle Stephens was a central figure in the professional lives of generations of teachers. His work kept them traveling hopefully. For those who know him only through his writings or reputation, he should be a starting point for understanding history, relationships, and the nature of doctoring. Fortunately, the extensive bibliography of his writings and the accompanying analysis by Geyman,² and the extensive collection of his work found at the Center for the History of Family Medicine, should keep his insights available as family medicine and general practice move into a time of organizational and policy change. One hopes his work will also help reaffirm the values that he felt should inform the work of generalists.

In a plenary address in the early 1970s, Stephens outlined the deep historic and intellectual tradition that underpinned the new discipline of family medicine. That speech became “The Intellectual Basis of Family Practice,” which served as seminal document in the history of generalism in the 20th century.³ He spoke at a time when debates within the field left a nagging feeling that family medicine might, in fact, be the trade school discipline that medical schools accused it of being.⁴ Many practicing family doctors expressed a disdain for academics in favor of what they called “the real world,” not recognizing, of course, that the new teachers were trying to work on their behalf in the real world of medical schools and academic health centers. Stephens spoke of a historic continuity with philosophers and scholars. He talked about Michael Balint and his work with British general practitioners, and he cited authors from religion, philosophy, sociology, history, and science as ancestors. Stephens also debunked the discipline's own myths as well as those that were constructed about it: that reductionism, rather than integration, was the true work of science, and that all problems have a technological solution.

In 1984 Stephens decided to bring together some of his long-time associates with younger people from a wide variety of professional backgrounds to reflect on what had happened since the founding of the discipline 15 years earlier. Gayle believed that, without examining history, the discipline ran the risk of history becoming a fairytale rather than a gritty social history. With a small amount of institutional sponsorship, Stephens held the meeting in Keystone, Colorado, a resort near his family's mountain home. Everyone who was invited had to pay their own way. And everyone came. He demanded candid discussions of competing forces, competing personalities, and the internal conflicts that made the evolution from general practice to family medicine a story of starts and stops, of trial and a great deal of error. He and his cohort talked of the collusion of forces and people at a time when society was finally ready to accept their ideas. The published and unpublished materials from that meeting were the first public reexamination of the academic and political origins of the discipline of family medicine.⁵ That gathering, and that spirit, served as an inspiration for 2 subsequent meetings he helped organize. In 2015, his legacy inspired Keystone IV, which was to be an ongoing series of symposia, named in his honor and supported by the American Board of Family Medicine Foundation.⁶

When they created academic family medicine, the founders had been in their 30s and early 40s. The discipline was created by young people. By the time of the first Keystone meeting, most of the founders were in their mid-50s and early 60s, and 1 of their unstated questions to the younger generations was, “Now that you are inheriting the responsibility for this discipline, what do you plan to do with it?” Since that time, all the Keystone conferences have been organized to ensure intergenerational conversations and a diversity of opinions and experiences. Thirty years later, the young people at the first Keystone are now the senior generation and are asking the same questions of subsequent generations. There is no anchor leg to this relay race, only the next leg, and the one after that.

Stephens was a writer and thinker and teacher and leader whose ideas and convictions still guide the work of personal doctoring. His insights into the relationship of doctors and patients were deeply psychological, spiritual, and practical. His heart and purpose were with the practicing doctor whose daily work he treasured. He wrote about the pain in the life of the patient sitting in the room with him and constantly tried to understand the context that surrounded that patient. Well into his 70s he continued to do a periodic locum in his brother's practice in rural Kansas and returned with stories and energy. He got much joy from the mystery of what William Carlos Williams called “the wonderful opportunity to witness the very words being born.”⁷ He loved that opportunity and, in his writings, would tell story after story about its appearance. Stephens warned against arrogance, self-satisfaction, and laziness. He was not a nihilist about technology but felt that it should serve patients, not the corporations that owned it. He wanted to see rigor in research and exhorted investigators to engage in research that mattered to patients and communities. The task, he would say, is to integrate information with values, but his concern was always about losing track of values in the fascination with the data. He wrote and talked about how immersion into what he felt was a sacred trust between doctors and patients was an act of service, humility, and hard work.

But his writings also serve as a warning for the discipline to continue to look outward to the social forces and history that created it to serve as guides for the future, rather than be preoccupied with internal conflicts. In perhaps his most often quoted article, “Family Medicine as Counterculture,” he worried that “we have expended our energy on professional legitimization and enfranchisement rather than reform.”⁸ He famously compared family medicine by contrasting the inclusiveness of a sect with the orthodoxy of beliefs, practices, and judgements that constitute a church. Stephens would continue to question orthodoxy and advocate for reform that preserved the fundamentals of personal medicine throughout the rest of his life.

Gayle felt that the nature of the therapeutic relationship compelled physicians to serve as guides not arbiters, supporting patients in their decisions, not judging their motives. He understood the complexities of the commitment to stay with the patient and realized the burdens this presented. His anger was directed at systems and organizations that created barriers, structural and economic, to the continuing connection between doctors and patients. Gayle used the term healer and felt that, just as physicians desired to play that role for others, they needed one for themselves. He believed that physicians need to be inclusive and caring, to work for the civic good and to believe in the commonweal. Gayle's belief in forgiveness rather than punishment and in a benevolent rather than a wrathful God was central to his work. He pointed out that physicians did not need to be reminded of their failures and shortcomings, since they carry those forever. Gayle felt that the work of doctoring would always be his reward and that there was solace in that work. He struggled with the tension between selflessness and selfishness, between humility and hubris, and with the challenge of being both one's doctor and one's friend.

For almost 50 years, Gayle Stephens kept following the carnival of health reform and publically and persistently wrestled the bear: the intellectual and political paths of a discipline he helped found. Stephens always believed in the possibility of great things. He trusted they would happen and we, collectively, could bring them about. He wrote passionately about the humanity and seriousness of medicine because he believed that doing so would help family doctors keep a clear head when threatened by the continuing crush of change. He brought colleagues together at the first Keystone to begin a necessary conversation. That conversation has continued over the past 30 years and must continue where ever family doctors work, care, teach, and struggle.

• Received for publication December 14, 2015.
• Revision received February 23, 2016.
• Accepted for publication March 2, 2016.