Dr Shadd’s argument in favour of palliative care as a subspecialty 1 hinges on a tautology: that any area of medicine is either a specialty or subspecialty or not. His argument can be reduced to the following statements:
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Family medicine is a specialty (as declared by the College of Family Physicians of Canada in 2007).
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All specialties contain subspecialties.
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Family medicine, therefore, has subspecialties.
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Subspecialty has a clear definition (according the Royal College of Physicians and Surgeons of Canada.
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Palliative care fits the definition of a subspecialty.
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Palliative care, therefore, is a subspecialty.
However, this is not really a debate about whether or not palliative care fits into a Royal College definition, especially because this definition has not been adopted by family physicians or integrated into family medicine training or organizational structures.
Should palliative care be a specialty? This is a normative question. It is a question of values, a question of how things ought to be. It is not a positive question, a falsifiable question, or an issue of definitions and categorization. Dr Shadd’s positivist answer to a normative question assigns palliative care to the set of subspecialties, but offers no cogent argument for or against the question at debate. Just because the College of Family Physicians of Canada has asserted that family medicine is a specialty—just because family doctors can now hold contradictory titles like “generalist specialist”—does not de facto lead to the conclusion that family medicine must have subspecialties. If we are to properly address the pressures to introduce family medicine subspecialties, family physicians will have to identify and articulate the meaning and value of generalist practice. We will have to engage with other normative questions: Should family medicine have subspecialties? What would we call these doctors—subspecialist-generalist-specialists? What would family medicine subspecialties mean for the spirit and affirmative practice of generalism? What motivates our discipline to engage in the fracturing of medicine and the denaturing of health care into ever smaller pieces?
Is any of this a good thing?
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