I support Dr Hennen in opposing the move to call general practice a specialty.1 In fact, I was one of a diminishing number of GPs present when Dr Irwin Bean of Saskatchewan argued against the change of name from general practice to family medicine in the early 60s—I tended to agree with him. However, I changed my letterhead, enthusiastically supported the renamed organization, became the first Certificant in Maple Ridge, BC, and was delighted to be honoured as a Fellow. But I think now that the term family physician is (sadly) too ambitious in the present context.
A primary care doctor has to be a generalist. She has to be ready to respond appropriately to any medical problem that presents to her on the street, in her office, or in the hospital. She is a generalist. She does not have the luxury of restricting her practice. The task is large and it is the first priority. Those physicians who have the talent to add a special skill are to be admired, as long as it does not undermine the commitment to generalism.
Again, the task is large. Lawrence Weed, the founder of the problem-oriented approach to care, suggested many years ago that GPs should be paid more so that they could provide more time than specialists for their consultations. He pointed out, as Michael Balint and others have done, that adequate exploration of an unorganized illness requires adequate time. There is a danger in organizing illness prematurely and inappropriately, partly because the organization might determine later referral patterns.
The GP’s tragedy in providing ongoing diagnosis and management is that she will always have an ethical imperative to refer patients to consultants whenever there is someone available who can do what is necessary better than she can. GPs are always having to let go. Of course, GPs do not and cannot know everything. The message is that the service must be determined by the needs of the patient, not by the FP’s personal interests or preferences.
It is a tragedy and a disgrace that we have the current shortage of FPs/GPs. The decision, made by government approximately 15 years ago, to cut medical school enrolment was disastrously wrong. Ironically, the College of Family Physicians of Canada has probably inadvertently worsened the situation. I have personally been involved in some of the programs to foster improved quality of care, specifically improvements in medical record-keeping and patient-centred care. This, with the rapid advancement of knowledge and the emphasis on evidence-based medicine, has actually made the work of GPs/FPs more difficult. It has become more satisfying to care for fewer patients with greater depth.
Dr Bailey has suggested that practice by physicians in teams or networks can help to meet community needs, and this is true. The main benefit, however, will come from 24/7 access to FP/GP care for patients, better opportunities for collegiality, and better off-call time for doctors.
Multidisciplinary teams with allied health care providers can also be valuable. However, great care has to be taken in spelling out the scopes of practice and the formal relationships within the team. It is essential to ensure that the appropriate expertise and authority of the physician (in medical matters) is acknowledged and honoured. Also team functioning and decision making can be very time consuming. Finally, the dilution of personal responsibility can result in patient disempowerment when the team is perceived as “ganging up” on the patient.
I believe that organized medicine has been remiss in not recognizing sooner the dilemma of governments faced with escalating costs. It seems clear that primary care reform will require a change in the system of remuneration for physicians. I personally would support remuneration that fosters population as well as continuity of personal care by physicians, provides some predictability of income, and fosters teamwork. The UK system of payment by capitation (with appropriate enhancement incentives) seems to come closest to providing this.
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