Focusing on generalism

Cal Gutkin

Areas of special interest have always been an important and valued part of family medicine. In recent years, however, although most family doctors still provide a broad range of services, many have reduced the comprehensiveness of their practices to provide more focused clinical care for patients. Why is this happening? Some decided to pursue personal career interests. Others have abandoned broader-based practice because of overwhelming patient demand related to more specific care needs. Some had to sacrifice their roles as community-based generalists when institutional appointments stipulated that special interest commitments must be full time. Residents have also reported that some faculty role models discouraged them from incorporating added skills into future broad-based practice, suggesting that maintaining competence in these areas required full-time commitment.

The CFPC’s priority was, is, and will always be to promote and support comprehensive continuing care and the role of FPs as generalists. The recognition of family medicine as a specialty affirms the knowledge and skills required to be an expert generalist as core to our discipline. Generalism is also at the heart of both the CanMEDS–Family Medicine medical expert role and the CFPC’s Triple C competency-based curriculum for family medicine residency training; and CFPC policies related to the delivery of family practice services are committed to generalism.

In 2006 the CFPC Board decided to reconsider proposals from FPs across Canada with special interests seeking our College’s support for networking, continuing education, and advocacy related to specific areas of care they were providing. Some also proposed accredited enhanced skills training and recognition of those demonstrating added competency in given areas. In the past, Board members’ concerns that such support would accelerate the fragmentation and destruction of comprehensive family medicine had always carried the day. But it had become apparent that not supporting these colleagues had not impeded the movement toward narrower scopes of practice. It was time for our College to pull its head out of the sand and assume the leadership role it should be playing as a key voice dedicated to maintaining comprehensive continuing care at the core of our discipline. It was time for us to ensure that special interests would be incorporated within, rather than external to, comprehensive family practice.

Most FPs with special interests seeking CFPC support included their added services within broad-based practices. Some, however, had devoted all their time to particular clinical areas, and a number had become clinical, teaching, and research leaders in their enhanced skill areas. All still saw themselves as part of the discipline of family medicine and viewed our College as their professional home.

In 2008, the Board approved our Section of Family Physicians with Special Interests or Focused Practices (SIFP), with its prime objective being to create a future in which added skills and services taught and practised by FPs would be part of comprehensive family medicine. All participants on SIFP committees must be committed to this objective. To be accredited, enhanced skills training programs must meet the standards of the Triple C curriculum: ie, the training context must ensure that additional skills are part of comprehensive continuing care centred in family medicine. The CFPC will continue to grant Certification only in the specialty of family medicine (CCFP). Recognition of added competence will be in a limited number of areas via designations that can be attached to one’s CCFP. The College’s vision for the future of family practice in Canada—the Patient’s Medical Home—recommends that every family practice offer a full scope of services provided by each patient’s personal FP working together with other health professionals, including FPs with special or added skills.

Throughout these deliberations the CFPC appreciated the input of many rural members who advocated for SIFP. Like their urban colleagues, they have indicated their interest in developing enhanced skills in order to help them offer services required by their patients—a need that is often greater in rural than in urban settings owing to limited access to other specialists. Most rural FPs continue to incorporate special interests into broad-scope practice—a model we would prefer everywhere. But many of them also remain concerned that offering enhanced skills training programs could result in many FP residents becoming “mini specialists” better prepared for narrower-scope urban practice than for rural settings, which they might perceive as being incapable of supporting them. We must all work together to ensure this does not happen. In addition to the rural FPs participating in our SIFP, the Society of Rural Physicians of Canada has been invited to sit on our SIFP Council. Their input has also been part of the important Health Canada–supported Future of Medical Education in Canada postgraduate project, planning important changes to residency training across Canada.

Urban and rural voices both need to be heard as we address these challenges. We must all be accountable to the populations we serve, assuring them that we are training and supporting FPs first and foremost as generalists and bringing their enhanced skills and special interests back into the house of comprehensive care where they belong.