The both of us

Every good story needs some conflict, and I think the old western films did it best. They always had a great setting—the dusty streets, the hastily constructed wooden buildings, and the townspeople just trying to survive in the new frontier. Inevitably tensions would rise, and the powers-that-be would face off across the main street because “this town ain’t big enough for the both of us.”

Sometimes I see these old western standoffs unfold in medicine. On one side of that dusty street, a gastroenterologist and a surgeon stand ready, hands poised to draw their weapons of choice, the scope and the scalpel. On the other side stand a family doctor and a hospitalist, the first reaching for his holster emblazed with the golden letters FIFE and the other ready with a comprehensive discharge plan. The ironic bit is that the opposing sides are actually working for the same cause—the health of the townspeople—and this requires teamwork.

The old adage “many hands make light work” applies both to those trying to survive the new frontier and to medicine. Among generalists, there is recognition that teamwork improves patient care¹ and team effectiveness.² Improving intrageneralist teamwork has been a focus of recent research. Howard et al (page e185) surveyed Ontario family health teams and noted that leadership, culture, and use of more electronic medical record capabilities predicted positive team climate in generalist settings.³ But comprehensive care requires generalists and specialists.⁴

The cultural divide between generalists and specialists has existed in Western medicine since ancient Greece,⁵ but it has been increasing as more subspecialties develop. Manca et al (page 576) describe specialist culture as being focused on technology, concepts, and specific details of diseases and organs.⁶ They propose that specialized medical culture delineates areas of focus and expertise by limiting access to valued resources, setting boundaries, and socializing others according to their areas of expertise. Generalists, on the other hand, treat both differentiated and undifferentiated disease, focusing on the patient not the illness. Based on that description I am happy to count myself among the generalists, but I think there is more to the story. Generalists rely on specialists to perform surgeries and highly specialized procedures and to manage very rare diseases. However, as the cultural divide widens, so too does the tension between the factions.

Unfortunately, patients are not immune to this tension. Family doctors often encounter patients returning after specialist appointments to “get your opinion” on the suggested course of treatment. It is flattering that our patients hold us in such high esteem, but have we actually done them a disservice by not demonstrating trust in our specialist colleagues so that our patients feel safe in their care? This might delay important investigations and treatment—and unnecessarily strain health care resources.

Conversely, a patient might begin an encounter with a family doctor by advising, “I just need you to make a referral.” After some preliminary questions about the chief complaint, the patient interrupts with, “No offense, but you’re not a specialist. I want to see the [fill in specialist here].” Family doctors specifically chose to be generalists and have the ability to triage chief complaints, help patients manage concerns immediately, and facilitate referrals should they be required. Perhaps this patient saw a specialist in the past who did them the disservice of not demonstrating trust in generalists. Patient distrust is a source of frustration for physicians on both sides of that dusty street, and it serves to deepen the divide between specialists and generalists, to the detriment of our patients. As Manca et al suggest, physician-physician relationships might be as important as doctor-patient relationships to providing high-quality patient care and improving health system efficiency.⁶ Facilitating a comprehensive culture in the medical profession, which values both specialists and generalists and emphasizes collaboration, is essential to improving physician-physician relationships.

The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada recognize the importance of this relationship,^7,8 and research is being done to improve this interaction. François (page 574), for example, has developed a tool to assess the quality of consultation and referral requests in family medicine.⁹ With continued efforts from both generalists and specialists, the gap between our cultures can be narrowed. Although the adjustment might be difficult, the gains will be great. This town needs “the both of us,” and the townspeople will benefit from the peace and security that result.

• Copyright© the College of Family Physicians of Canada