Sitting and thinking

Garey Mazowita

I write this in the air midway to Family Medicine Forum, our board meeting, and my installation as President. Lots of air travel last year, as President Elect; lots of time to sit and think. This has been a luxury. It is something I, like most of you, don’t get time to do. The air travel is not such a luxury, but the destinations, members, and organizations at the end of my travels have been gracious, inspiring, and enormously informative. Sitting and thinking for me encompasses a blend of changes in the larger world, the march of generations, current challenges, and my place in it all. The past is occasionally illuminating; at other times I’m left shaking my head. I wonder how being a family doc colours my view of the past, and how my past colours my work.

I think back to my biases and assumptions as an intern: I recall “ragging” my classmates in FM residency about “doing throat swabs” while I was putting in central lines in the ICU. Two years later, on my first day in my new practice with absolutely no postgraduate FM office experience, my senior partner “booked me lightly, to start me off.” At 8 pm I had unhappy, frustrated patients who had still not been seen because I felt compelled to do thorough histories and physicals on everyone for fear of missing something.

Those first years in practice—busy with obstetrics, office practice, nursing home care, housecalls, and emergency, ICU, and on-call shifts—I felt like I could go on forever, so improved was the work-life balance compared with life as an intern. Years later I joined a teaching clinic at the University of Manitoba. A few weeks in, experiencing formal residency meaningfully for the first time, I thought to myself “these residents would have received better experience in my office practice.” A year later my tune had changed as I came to appreciate the value of my allied health colleagues, our group practice, the stimulating educational milieu, and my own inability to sustain my pace without these supports. Now I had colleagues to share call with, to consult, and to mentor and be mentored by, and access to faculty development, despite still doing a lot of obstetric and inpatient care.

I remember many excellent residents and colleagues: amazing, inspiring folks who made me think our future was in good hands. I remember others, not-so-good: a minority that gave me cause for concern. I recall learning to understand my responsibility in maintaining my quality of care, to grapple with worrisome care by others, and to value continuing education and quality improvement and assurance.

I recall looking after patients in long-term care—being dismayed by some places and thinking of others, “I wouldn’t mind spending my last days here,” and reflecting on why. No surprise, it was most often the skill and commitment of the staff and a clear philosophy and culture of care. The same for my inpatient care experiences.

I recall being flummoxed by my first patient with florid borderline personality disorder. From this grew my interest in mental health and immensely valuable experiences with our community hospital psychiatric ward and outpatient service.

I recall with fondness specialty colleagues who collaboratively gave me and my patients exactly what we needed to move forward, and others less fondly who obfuscated and came nowhere near answering the questions I had asked. I particularly recall a number of patients refused medical disability and coming to understand the responsibility I had to advocate for those I believed were wronged. I was also struck by how easy it was to avoid the advocacy role, and the profound ramifications for patients of doing so.

I recall the marginalization of family practice in our community hospital: in 2 years going from a vibrant department to a decimated membership, fractured by an administrative decision to move to an increasingly specialty-oriented model that parsed patients into body parts or diseases.

I remember the joy and privilege of delivering children of patients whose own births I attended and of caring for hospitalized patients whose families I also cared for—and how much better the journey was for all. And, of course, I remember the indelibly humbling experiences of learning from my dear patients, unfortunately at times at their cost.

Such things make us who we are, shape our biases, and inform our understanding of current problems and how to address them. The world changes; new doctors have different experiences, histories, and ideas relevant to the future of our discipline. We must look forward, be appropriately critical of our solutions, open to the ideas of others, and aware that we are inescapably captives of our histories. I was pleased by recent reaffirmations of family medicine and generalism, but I worry about the forces teasing apart continuous, comprehensive care. My gut tells me there is an important equilibrium to maintain between comprehensive and focused care—we must remain “one family” in family medicine. I am amazed by the energy and capabilities of our newest FPs and residents. I am hopeful for a sustainable future, but I am intimidated by the work ahead for our College as we toil to build key partnerships, navigate evolving roles and responsibilities, and ensure our educational model remains relevant and sound. These are challenges for all of us.

I invite your correspondence and look forward to meeting you. Our new governance model provides unprecedented opportunity for a member-driven CFPC in which we can distill the wisdom of the old and new, embrace all practice settings and styles, and engage the public so that when we do sit and think back, we can affirm our journey.