Turf wars?

Driving home one evening, I heard Brian Goldman from “White Coat, Black Art,” on the radio. He was responding to the release of the Primary Care Wait Times Partnership (PCWTP) report.1 He thought the College of Family Physicians of Canada (CFPC) was unrealistic in its goal for 95% of the population in every community in Canada to have family physicians by 2012, that much more needed to be done to increase the number of practising international medical graduates (IMGs) in Canada, and that the College was protecting its turf.

Well, this was certainly interesting—and good fodder for some controversy—but is it really fair to say that the CFPC is unrealistic and protecting its turf?

The PCWTP report was a joint initiative of the CFPC and the Canadian Medical Association, and it describes and makes recommendations about wait-time problems, including for those who are without family doctors. The media responded strongly to the release; however, most focused not on the recommendations of the report but on the vision statement that the CFPC had actually released in 2007—for 95% of the population to have family physicians by 2012. When this was first announced in 2007, it was put forth as a challenge, something to reach for—hence the term vision statement. There is no organized pan-Canadian health human resource plan. We need one. No one else is setting these goals. As the voice of family medicine in Canada, and given the College’s mission to support ready access to family physician services, I think we had to do it.

To make a difference we must dream, stretch, and think beyond what seems possible—that is the vision of the statement and an important part of leadership. Elbert Hubbard wrote that a goal without a plan is a dream. The PCWTP report and other CFPC documents, including our recent discussion paper on the medical home,2 are blueprints articulating how to turn dreams into realistic goals. The Association of Faculties of Medicine of Canada’s recent paper on the future of medical education is also a piece of the plan.3 We need a vision for what can be achieved and we must continue to find solutions. We need a national approach and we cannot sit back and wait.

Is the goal realistic? I am an optimist and I like having goals that aim high. The report on wait times and the medical home paper both describe strategies that would help us reach our target. Both cover new models of practice, including innovations in scheduling and team approaches that could increase capacity in existing practices. There are examples now of family physicians in Canada who had full practices and long waits and who moved to open-access appointment scheduling models that enabled them to catch up and even begin taking new patients.4 We also support another vision: that each Canadian will have access to a primary care setting where his or her care will be provided by a personal family doctor and a registered nurse or nurse practitioner. We are involved in many initiatives that support collaborative, interprofessional, team-based care. We have been championing this for years. As these strategies take hold, we move closer to our goal. Is that protecting our turf?

Practising differently is one part of the plan. Increasing our numbers is another. Medical school enrolments have increased across the country, with more than 2700 students entering medicine each year. In total, there are now 10 500 medical students in Canada. The proportion choosing family medicine has been increasing since 2004. This is not a blip but a solid trend. Let us continue to build on last year’s results of more than 32% choosing family medicine. Since 2004, the number of first-year family medicine residents has doubled to more than 1200. The number of programs across the country has exploded, as academic departments of family medicine embrace distributed and rural programs. There are now 2350 family medicine residents in Canada, and in 2009 a further 262 were in thirdyear programs. Family medicine programs have also been very involved in training IMGs. The number of IMGs practising in Canada has also been on the rise in recent years.

Dr Goldman talked about how important IMG physicians are—and I agree. But there are ethical questions that he did not mention. Is it really okay for Canada to solve its resource problems by recruiting from countries that can ill afford to lose their health care workers? Should we not be striving to be mostly self-sufficient or, even better, to do more to help address global health issues?

Leadership is about vision—seeing the possible and providing a plan. The College has done both. So how will we know if we are getting there? Head-count statistics have not proven helpful in assessing population or resource needs, but the National Physician Survey is being conducted again this year. No other survey provides more insight into how we are doing in pursuit of our vision.

Criticism is good. Feedback is good. Thank you, Dr Goldman, for making us think and for reminding us why we all need to fill in our surveys when they come!

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