Is family medicine a specialty?

Over the past 2½ years, our College has been deliberating a directive from our Board of Directors to explore acknowledging family medicine as a specialty. We have welcomed the input of many family physicians, other medical and health professionals, medical students, residents, medical school deans, government and licensing authority officials, members of the media, and the general public. The support for moving forward with the acknowledgment of family medicine as a specialty from each of these constituencies has been substantial. In fact, many indicated they thought this had already happened years ago.

In many countries, including those where it is referred to as general practice, family medicine has been recognized as a specialty for decades. When postgraduate training and Certification in family medicine were introduced in Canada in the 1970s, many believed that it had become a specialty here as well.

Many with whom we met pointed out that family medicine, like the already recognized specialties, has a defined body of knowledge, skills, and attitudes; a growing research base; a postgraduate training program; and a Certification process. As well, they told us, family physicians play a highly valued role in the provision of medical care in Canada.

Many of the same people also indicated, however, that family medicine does not currently enjoy the image, respect, and credibility it merits. The reason for this, at least in part, is that family medicine is not recognized as the specialty it is.

Recent years have seen a downturn in the popularity of family medicine as a career choice for medical students. Practising family physicians, particularly those trying to provide comprehensive continuing care, report a reduced level of satisfaction.

In order to address these problems and to enhance the image of family medicine, our College has conducted meetings, focus groups, think-tanks, and surveys that have helped us to identify a range of factors contributing to the challenges facing family medicine.

Medical students suggested that one of the factors that serves the image of family medicine poorly among their student colleagues is the recognition from very early in their medical school years that family medicine is not considered a specialty. As a result, it seems to be less respected and less credible as an academic discipline than the recognized specialties to which the students are being introduced at the same time.

Many former Certificants who discontinued their College memberships and gave up their Certification told us that they did so because, other than being required for academic appointments, holding CCFP designation had not distinguished them from their non-Certificant colleagues.

Many Certificants indicated they would greatly appreciate our College doing something to increase the value and meaning of the CCFP designation.

Although the effects of acknowledging family medicine as a specialty are not predictable, historically physicians in other disciplines found that benefits, such as appointments, promotions, and increased remuneration, often followed the recognition of their areas of practice as specialties.

Concerns have been raised that acknowledging family medicine as a specialty might undermine the valuable role that non-Certificant family physicians play in their practices and communities. Many of these family physicians who have been in practice for a long time have told us that they never tried to achieve Certification because they felt the CCFP examination was not an appropriate or fair way to assess the competency of experienced practitioners like themselves.

The College highly values and respects the contribution of these colleagues to patient care across Canada. Our Board of Directors has made it clear that its position is that qualified family physicians who have been in practice in Canada for many years and who choose not to attain Certification should not be pressured to have their roles changed or be denied any of the privileges they have earned to this point in their careers. For those who still wish to attain CCFP designations, however, a special working group is developing a proposal for a time-limited alternative path to Certification without an examination. For the longer term, another working group is developing a new practice-eligible examination for experienced, practising family doctors.

Some colleagues have also expressed concern about the possible loss of a generalist focus if we acknowledge family medicine as a specialty. As happened in other countries where family medicine is now a specialty, most here have also come to understand that this is not a debate about generalism versus specialization, or about the sacrifice of the essential generalist focus that defines family practice.

Many Royal College specialties are now also looking at increasing the generalist focus for physicians in their disciplines. As a result, there has probably never been a more important time for family medicine to be recognized as the specialty that can and should assume a lead role in the teaching, practice, and lifelong learning related to generalist skills. Despite its central importance to our discipline, generalism is not owned by family medicine—nor should specialization be limited to the disciplines of the Royal College.

Family medicine today is being challenged in ways that require new thinking to define and ensure its meaningful future role. Many different solutions are being recommended and implemented. Acknowledging family medicine as a specialty is only one of them. But it is an important one, and most of those who have been consulted believe it will enhance the image and value of family medicine and family physicians in Canada. It will help instil pride in family doctors who practise, teach, and carry out research. It will deliver a message to medical students that family medicine is a career choice equal to all other specialties.

The time has come to recognize a reality that has been in place for decades—family medicine is and deserves to be a specialty in Canada.

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