Is family medicine a specialty?

General practitioners … are the doctors closest to people. They heal most of the broken-hearted, repair more of the injured and deprived, and live with the poor and dying who are without hope. Adaptation is the juice of family medicine—the GP adapts to the needs of people or closes up shop.

William Victor Johnston1

What are the health needs of Canadians to which family doctors must adapt in this 21st century? Is a medical work force composed entirely of specialists what Canadians require?

Recent reports have the common message that Canadians need family doctors. Fifty years ago L.W. Batten wrote that the family doctor’s practice is general, does not know the limitations of a specialty, and is concerned with the whole person and with the whole field of medicine.2 Valid today? Definitely. But what exactly does “general” mean? What are the limitations of a specialty?

What does general mean? Family physicians’ knowledge is of the breadth of medicine. They never say, “There is nothing I can do for you.” They commit to a continuing personal relationship. They care for people of both sexes and any sexual orientation, from before conception to death, and apply their medical knowledge and technical skills to all presenting problems. For problems that they determine to be outside their expertise, they coordinate the services of specialists for their patients’ benefit.

In 1990, David Morrell wrote about the infinite variety of problems presented to general practitioners. He cited a study by 2 colleagues who, over 2 weeks, saw 1410 adults present with 31 symptoms (average of 3.9 symptoms) and 519 children present with 26 symptoms (average of 1.3). Morrell noted that GPs are expected to have opinions on a variety of subjects—physical, psychological, and social. He emphasized the importance of continuity of relationships and the accumulated knowledge about patients that results.3

In a 2005 survey sampling 1600 of 380 000 Nova Scotians in the Capital Health district, Fred Burge noted that 96% had family doctors. The median time they had been seeing their doctors was 14 years, an impressive confirmation of continuity.4

Morrell further noted family doctors are their patients’ first contact, their most important function being to interpret problems presented to them in terms of their patients’ needs.3 Seeing problems from the patient’s perspective was emphasized when Ian McWhinney5 and Moira Stewart,6 with their research team, refined the patient-centred clinical method: “Because family doctors are available for all types of problems, they can make no prior assumptions about why the patient has come.”7

These reports speak to the generalism of family practice and the importance of continuity of care.

What are the limitations of a specialty? Specialists have boundaries around their knowledge, skills, and practices. General pediatricians limit by age, general surgeons by the type of solutions they offer. General internists stick to adults with biomedical problems and general psychiatrists to mental illness. Family doctors have no such boundaries. They are not specialists.

How does family practice fit into our overall health care system? Family doctors are the first-contact generalists who look after 80% to 90% of the problems that patients present and refer the remainder to specialists to help with diagnosis or management. McWhinney notes, “If any organization is to remain healthy, it must have a balance between generalists and specialists.”5 Such a balance exists now for Canada’s doctors (although concerns exist about maintaining the ratio of 1 family doctor for every specialist).

To consider or not consider family practice a specialty is not a new debate. One name considered for our College by the 1953 Canadian Medical Association council was “College of Generalists.”7 In 1967 many members resisted changing our name from the College of General Practitioners to the College of Family Physicians.

Medicine is a multidisciplinary professional enterprise bringing together scientifically educated doctors of many kinds, half of whom in Canada are currently made up of more than 50 specialist and subspecialist groups. The other half—our half—includes the generalists: family physicians or general practitioners.

Having apparently failed to convince our students and residents of the central place of the generalist in our system, we must do a better job of elucidating and celebrating that important and essential work as first-contact physicians, managing most problems and appropriately directing to specialist colleagues those patients whose problems we cannot solve.

If, however, we mistakenly assume the specialist’s mantle, we will become just another of the specialty groups to which other primary health care providers might or might not refer the problems they cannot solve. To call ourselves specialists in the face of our overwhelming immersion in generalist activities will confuse our patients, ourselves, our colleagues, and our students.

I have found it useful to distinguish between family medicine, the academic discipline that comprises the body of knowledge, and family practice, the clinical activity that encompasses our work in the health care system. I do not hesitate to describe the academic discipline of family medicine as a special body of knowledge.8 I accept that family practice applies a particular, patient-centred clinical method in which we are experts. But I resist with all my heart and mind that as a doctor I am other than a generalist.

If it looks like a generalist, talks like a generalist, and acts like a generalist, surely it is not a specialist!

• Copyright© the College of Family Physicians of Canada