Where is family medicine heading?

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Re:Re:Where is family medicine heading?
Nicolas Elazhary

Published on: 30 March 2016
Re:Where is family medicine heading?
Eric Letovsky

Published on: 04 January 2016
Is Family Medicine ready to look where its heading?
Franklin H Warsh

Published on: 24 December 2015
The joys of home visiting
W. Wayne Weston

Published on: 23 December 2015
What's happen to responsibility and professionalism in family medicine ?
Ross C. McElroy

Published on: 23 December 2015
Where is family medicine heading?
Thomas R Freeman

Published on: 23 December 2015

Published on: (30 March 2016)

Re:Re:Where is family medicine heading?
Nicolas Elazhary, Family physician and emergency room pacrtitioner
This is a longstanding discussion between the many forms family medicine can take where I come from. I have seen all types of reactions from people working only in a office setup telling residents they should not undertake a "specialized practice" in emergency medicine to the opposite inside the emergency room where some colleagues try to discourage residents from going to a more hospital or office set-up.
I do...
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This is a longstanding discussion between the many forms family medicine can take where I come from. I have seen all types of reactions from people working only in a office setup telling residents they should not undertake a "specialized practice" in emergency medicine to the opposite inside the emergency room where some colleagues try to discourage residents from going to a more hospital or office set-up.
I don't claim to have the wisdom to tell you if any of these approaches to "family medicine" is the correct one if we look at the health system as a whole and look at the needs of the population. I don't think most of our leaders can actually claim to know for sure what is the correct way to orient our residents for the good of the population. We can only make educated guesses and try to change our way of thinking when our first approach does not seem to work. Here is the problem I see when we try to orient a generation of residents or more: things change all the time and we cannot predict how they will change. If residents seem to be going to a more specialized way of practicing family medicine maybe it is not because our specialty is "eroding" but because the way we practice must change if we want family doctors that can do everything, at least for a while. Medicine is becoming so much more complex. I have been practicing for 10 years now and I see the changes everywhere already. Maybe we need to change the way we teach the program if we want doctors that will be confortable in everything. A good first step would be to ad a year to the training. If "specialized" practice seems to be preferred for residents these days it may be because they don't feel ready to do everything, let's give them the means to be better and more secure. Let's also build clinics where they can actually have access to the things that attract the "hospitalists": labs you can get in real time, X-rays and so forth. Let's adapt the office and other types of practices to make our colleges more at ease and efficient in the way they work. Let's put the clinic next to the hospital as some clinics have begun to do, so that they can have access to the things AND people necessary to do our job right in 2016. We teach residents to work with other professionals to get better results and work in teams, let's get that done in real practice not only in their training program. I know most of these suggestions are not strictly under our control as teachers but we could tell the people who could help in that endeavour what would probably work.
We preach to residents that they need to lead healthy life styles so as to stay healthy in body and in mind. One of the key features of staying healthy is to respect our limits. These limits cannot be argued on a rational level in my opinion. Residents and our new colleagues just feel when they are at ease in a certain way of practicing. If most go in a specific field of family medicine, maybe the problem is not always with the training program but sometimes with the way we still practice our trade in an era where the knowledge base is getting always bigger, where our level of competence needs to get better and better all the time, where results are expected... now not tomorrow after you get the blood work or X -ray you asked for.
I think abandoning the third year residency programs would be a bad idea. We would just be creating generations of residents who are less competent (at least when they start practicing). We have reached, I think, the limit to the amount of preparation we can give to resident in a 2 year program. If we want more form them we should give them more preparation and encourage better ways of practicing our trade.
I teach residents to get better in my "specialized" field witch is emergency medicine. I am proud to call myself a family physician anyway even if I don't see patients in an office (I know, some of my colleagues smile of frown when I say this). I think I am a family physician because of my approach to my patients and because I try to see the whole picture not only that the patient has chest pain today. I think I give an essential service to the population. After 10 years of practice I do mostly shifts during the night and evenings. Most of our colleagues that do other things beside emergency don't want to do these shifts and I accept that. I even respect my colleagues that only do office work because they follow so many patients on a regular basis. I respect my limits: I don't think I would be happy in a office setting. That does not mean the resident I teach would not be awesome in a office setting and in the emergency. Let's give him the means to do both or any other mix of tasks of our many faceted specialty. I work around 50 hours a week if I count the ER, university and all the other things that come with the many hats that I wear. I respect any doctor that does the work they have set out to do, does it well, takes care of their patients to the best of their ability and works more than the usual 30 hours a week. If we all do these things I think we can take care of the population and be happy in our practice. Moreover, if we are happy our patients will see this and be all the better for it, because they will know their doctor is happy to take care of them.
Again this is only my 2 cents on the matter, I do not claim to know everything. I just wish I did. :-)
Dr. Nicolas Elazhary M?decin de famille et C.C.M.F. M.U. Professeur adjoint de l'Universit? de Sherbrooke D?partement de m?decine familiale et de m?decine d'urgence C.H.U.S. Chef du comit? de recherche du d?partement d'urgence C.H.U.S. Directeur de l'ACLS et maitre instructeur pour le centre de formation continue de l'UdS Pr?-hospitalier de l'Agence de la Sant? et des Services Sociaux de l'Estrie
Conflict of Interest:
I am a teacher in a family medicine program as well as in the advanced emergency medicine program at university of Sherbrooke
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Competing Interests: None declared.
Published on: (4 January 2016)

Re:Where is family medicine heading?
Eric Letovsky
Other Contributors:
December 29, 2015 Letter to the Editor Canadian Family Physician Re; Where is Family Medicine Heading? Editorial Canadian Family Physician December 2015 vol. 61 no. 12 1029
Roger Ladouceur says in conclusion to his Editorial; "It's time we gave this some thought" with respect to his observation; "The more time passes, the more family medicine seems to erode. Where we once had family physicians, increasingly, we...
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December 29, 2015 Letter to the Editor Canadian Family Physician Re; Where is Family Medicine Heading? Editorial Canadian Family Physician December 2015 vol. 61 no. 12 1029
Roger Ladouceur says in conclusion to his Editorial; "It's time we gave this some thought" with respect to his observation; "The more time passes, the more family medicine seems to erode. Where we once had family physicians, increasingly, we seem to have emergency physicians, hospitalists, intensive care physicians, and even palliative care physicians." As Family Medicine trained Emergency Medicine educators, we have been thinking about these underlying issues our whole careers. Where Dr. Ladouceur sees "erosion" we see evolution. Where he sees failure we see excellence to be applauded.
Dr. Ladouceur mentions "aesthetic medicine, phlebology, or psychotherapy...." as lamentable career choices for our graduates and we would agree. Of interest, he does not lament urban office based practice that is restricted to bankers' hours; he only singles out "focused" or "specialized" practices. Yet those family physicians focusing on emergency care, hospitalist care,, intensive care and palliative care are all choosing demanding , high acuity areas with a burden of unsocial hours. We would suggest those filling gaps like these are far more responsive to the needs of our patients and communities than the urban office based practitioner who never delivers a baby, enters a nursing home (at least not after hours) or sees their dying patients at home or in the hospital.
With respect to graduates of the Emergency Medicine Fellowship program - those who receive the added competence designations Dr. Ladouceur is so concerned about, we have informally and formally followed the careers of graduates of our program at the University of Toronto.(1). We found that over their life-cycles, most graduates of the emergency medicine fellowship did some Family Medicine and many (40%) ultimately chose to do office based Family Medicine exclusively. Many (40%) worked at least some time in an underserviced area and most (57%) had held leadership positions of one kind or another. Less than half were doing full time EM at time of the survey. Thus we found that we were graduating future leaders who chose a mix of Family and Emergency Medicine at different times in their careers.
Most importantly however, the care for certain patient populations, like those served by palliative care and emergency medicine has improved so dramatically in the last 20 years precisely because some family physicians narrowed their clinical focus, developed an area of expertise, and provided local, national, and even international leadership to transform clinical practice. As just one example, if it wasn't for the late Dr. Larry Librach, a family physician who became "only" a palliative care physician, palliative care would be 20 years behind where it is now.
Ultimately as educators and medical leaders we must be responsive to the needs of our patients and communities. The ideal of the comprehensive Family Physician is a valuable one, but clearly is increasingly challenging when medical knowledge is exploding and practice is increasingly complex. We all have to work together to continue to design career trajectories that are sustainable, responsive to our patient's needs, and responsive to the needs of the health care system. Rather than bemoaning the loss of the "comprehensive "family physician, we should be celebrating the successes of all of our colleagues who are transforming health care to the good.
Howard Ovens MD, CCFP(EM), FCFP Chief, Dept. of Emergency Medicine, Sinai Health System and Professor, Dept. of Family and Community Medicine, U. of Toronto TC LHIN Lead for EM and ON Provincial Lead email:howard.ovens@utoronto.ca
Eric Letovsky MDCM, MCFP(EM), FRCP Chief, Department of Emergency Medicine. Trillium Health Partners Director and Professor, Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto ED Lead, Mississauga Halton LHIN email: eric.letovsky@triiliumhealthpartners.ca
John R Foote BSc MD CCFP(EM) Director of Emergency Medicine Residency Program Assistant Professor, Department of Family and Community Medicine, The University of Toronto Staff Physician, Schwartz/Reisman Emergency Centre, Mount Sinai Hospital email : johnfoote@sympatico.ca
1. Practice patterns of graduates of a CCFP(EM) residency program; A survey. Varner, C, Ovens H, Letovsky E, Borgundvaag B Canadian Family Physician July 2012 vol. 58 no. 7 e385-e389
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (24 December 2015)

Is Family Medicine ready to look where its heading?
Franklin H Warsh, Family Physician
Dr. Ladouceur is to be commended for opening the door to hard questions for Family Medicine as a discipline. To zero in on Certificates of Special Competence as a part of the problem, however, risks overlooking evidence of a more worrisome problem.
Why are new grads restricting or focusing their practices? Outside of those working only Emergency Medicine (which has been an issue for at least 20 years), there can...
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Dr. Ladouceur is to be commended for opening the door to hard questions for Family Medicine as a discipline. To zero in on Certificates of Special Competence as a part of the problem, however, risks overlooking evidence of a more worrisome problem.
Why are new grads restricting or focusing their practices? Outside of those working only Emergency Medicine (which has been an issue for at least 20 years), there can only be two broad categories of reasons: remuneration and satisfaction.
Remuneration, under which I would include the economics of covering inpatients and house calls, is largely beyond the control of the College. These are to be negotiated between government and medical associations, (or, increasingly, imposed by provincial ministries).
If new doctors are dissatisfied, it's vital for the College to determine the main reasons why, and it needs to be done soon.
Is it the increasing burden on FPs to care for patients with mental illness, pain, and addictions? That can be addressed in residency and CME.
Is it the increasing burden on FPs to play quarterback for patients with multiple chronic illnesses? That can also be addressed in residency, and with expanded support for primary care-driven guidelines (such as the excellent new guidelines for lipid management).
If, however, new doctors are more globally dissatisfied with primary care, the discipline has a serious problem on its hands, and by extension, so do the medical education and health HR-planning systems. If everyone operates under the broad assumption that most family doctors practice family medicine, but new family doctors don't want the job, what will primary care look like in ten years? Will a full-service family practice be a quaint, romantic ideal for all but the most isolated and devoted practitioners? If that's the case, should the College continue to promote a vision of family medicine that's out of step with huge swaths of its workforce? Or should the CFPC take the lead and reinvent the profession, taking a hard look at every now-sacred cow?
Unfortunately, the consequence of inaction is a definition of Family Medicine determined by specialist whims and government mandates.
Franklin Warsh MD MPH CCFP St. Thomas, Ontario
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (23 December 2015)

The joys of home visiting
W. Wayne Weston, Family physician (retired)
Some of the best memories of my 40 years in practice are of housecalls. I think what makes them stand out was the opportunity to connect more deeply to my patients' lives and to get to know them more fully. I usually came away from a home visit feeling it had made a difference to the patient even if I could offer no cure or even change the course of their disease. There is almost always something we can offer to relieve...
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Some of the best memories of my 40 years in practice are of housecalls. I think what makes them stand out was the opportunity to connect more deeply to my patients' lives and to get to know them more fully. I usually came away from a home visit feeling it had made a difference to the patient even if I could offer no cure or even change the course of their disease. There is almost always something we can offer to relieve their suffering, their despair or loneliness. Sometimes it is our support for the caregiver in the family that is most important. It would be a tragic loss for us as well as for our patients if we gave up caring for our patients when they can no longer get to our offices. This is especially true when they are in the last stages of life when they need us the most. Postgraduate programs need to provide opportunities for residents to experience the joys and rewards of home visiting.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (23 December 2015)

What's happen to responsibility and professionalism in family medicine ?
Ross C. McElroy, retired GP/FP
I am grateful to Dr. Ladouceur for bringing up the question in his December editorial "Where is family medicine heading?"
It is a question I have been asking for 26 years. In 1989 Woodstock ON (an ideal trad. GP/FP location) was struggling to recruit traditional GP/FPs. A survey of FM residents in Ontario at that time indicated that only 50% intended to be trad. GP/FPs.
To provide support to Dr. Lado...
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I am grateful to Dr. Ladouceur for bringing up the question in his December editorial "Where is family medicine heading?"
It is a question I have been asking for 26 years. In 1989 Woodstock ON (an ideal trad. GP/FP location) was struggling to recruit traditional GP/FPs. A survey of FM residents in Ontario at that time indicated that only 50% intended to be trad. GP/FPs.
To provide support to Dr. Ladouceur's concerns, in the last 7 years the Woodstock ON hospital granted privileges to 24 GP/FP ER physicians and to 18 GP/FP hospitalists, but no trad. GP/FPs. During those 7 years two busy trad. GP/FPs retired leaving 4,700 orphan patients. Fifteen years ago with Dr. Bruce Halliday (past president of CFPC), I listened to Dr. Ian McWhinney (father of Family Medicine in Canada) share his concerns about the fragmentation of FM.
Are we witnessing in Family Medicine an erosion of responsibility and professionalism?
In the December 2015 issue of the CMAJ Dr. Cindy Forbes (president of the CMA) announced that the CMA will have a new strategic plan to focus on "hugely important issues next year such as professionalism" The UWO Meds 66 graduates Legacy Project to celebrate their 50th anniversary of graduation in 2016 is to institute an annual medical student prize for professionalism.
Family Physicians need to recognize the obvious, that medical schools exist to meet the primary care health care needs of Canadians and not just the life style goals of family physicians.
Ross McElroy RR#2 Tavistock ON retired GP/FP
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (23 December 2015)

Where is family medicine heading?
Thomas R Freeman, Family Physician
Other Contributors:
Thank you Dr. Ladouceur for pointing out the elephant in the room.
Hopefully, this editorial will stimulate an active and productive discussion within the discipline of family medicine and the College of Family Physicians of Canada.
Family medicine has been coasting on a reputation based on principles (see Dr. Michael Kidd's Ian McWhinney Lecture in the same issue of CFP) and practices that have been losin...
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Thank you Dr. Ladouceur for pointing out the elephant in the room.
Hopefully, this editorial will stimulate an active and productive discussion within the discipline of family medicine and the College of Family Physicians of Canada.
Family medicine has been coasting on a reputation based on principles (see Dr. Michael Kidd's Ian McWhinney Lecture in the same issue of CFP) and practices that have been losing momentum for some time. The 'primary care advantage' that has been so well documented by Starfield and others is in serious danger as family physicians opt increasingly for focused practices and those still involved in caring for a defined practice population reduce the scope of their practices.
Bazemore and colleagues recently found that those practitioners with a wider scope of practice provided care with lower costs and tended to have fewer hospital admissions. As hospital stays become shorter and more focused, and more home care necessary, it is particularly concerning that fewer new family medicine graduates see doing visits in the home as part of their future practices. In the early days of defining family medicine as a distinct discipline, Fox made this observation: "If I wanted to discover whether a doctor had a vocation for personal care, I should begin by asking what he [sic] thought about housecalls" (Fox, 1960).
The issue of whether the development and expansion of Certificates of Added Competency is causing more focused practices or are in response to larger social and system pressures is an important one to address. At present there is no discernible link necessary between population health needs and the decision of an individual practitioner to focus his or her practice. This leaves open the impression that it is driven more by life style and economic considerations rather than the needs of the community. I
n the United Kingdom, General Practitioners with Special Interests (GPwSI) must continue to maintain a general practice while taking referrals from their colleagues (Royal College of General Practitioners). The 'expert-generalist' is a role that has particular application in rural areas where access to specialty care is often limited (Fins, 2015). In this way they serve to shorten waiting lists to see specialists, keep care closer to the patients' homes, reduce system costs and maintain practitioner competencies. Ideally, such special interest and focused practices should be required to demonstrate a need for their services in the community and there should be an outcomes framework in place prior to Certification. Gervas, and colleagues outline important questions about special interest general practitioners that need to be addressed (Gervas, Robertson, Starfield et al, 2007). It is time that we in Canada seriously examine whether focused practices, as distinct from areas of special interest serve community needs or professional needs.
We should not be distracted by the presumed value of specialization. The importance of comprehensiveness and continuity, key principles in family medicine, becomes very apparent in interviews with individuals who have lost the benefits of having a family physician (Freeman et al, 2013). The generalist, personal physician provides care not available through focused or specialist practices.
A common refrain is that general family medicine is too complex and difficult. The latest Commonwealth Survey, (Osborn et al 2015) reported that Canadian family physicians felt underprepared to manage care of patients in their practice with dementia (42% felt prepared), palliative care (42%) and multiple chronic conditions (70%). Some will no doubt argue that the answer to this is to train more family physicians in these special interest areas of practice but, a better solution surely, is to provide more focus on generalism and an approach to all problems. For patients with multiple chronic conditions generalist family physicians are the most important innovation health care has to offer.
Dr. Beaulieu and colleagues have documented that family medicine is in the midst of an identity crisis (Beaulieu, Rioux, Rocher,2008). As McWhinney said: "Family physicians may be differentiated, but family medicine should not fragment" (McWhinney, Freeman, 2009, p.26). There is great need for our national College, provincial chapters, educators and researchers to take a leadership role in frankly confronting this crisis. Let 2016 be the year for this important work to begin.
Bazemore A, Petterson S, Peterson LE, Phillips Jr RL. More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations. Ann Fam Med. May/June 2015;13(3):206-213.
Beaulieu M-D, Rioux M, Rocher G, Samson L, Boucher L. 2008. Family Practice: Professional identity in transition. A case study of family medicine in Canada. Soc Sci Med. 67:1153-1163
Fins JJ. The Expert Generalist: A Contradiction Whose Time Has Come. Acad Med 2015. 90(8):1010-1014.
Fox TF 1960. The Personal Doctor and his Relation to the Hospital: Observations and Reflections on Some American Experiments in General Practice by Groups. The Lancet April 2, 1960: 743-760
Freeman TR, Brown JB, Reid G, Stewart M, Thind A, Vingilis E. Patients' perceptions on losing access to FPs: Qualitative study. Can Fam Physician 2013;59e195-201.
Gervas J, Robertson M, Starfield B, Violan C, Minue S. GPs with special interests: unanswered questions. Br J Gen Practice, November 2007: 912- 915.
McWhinney IR, Freeman TR. Textbook of Family Medicine 3rd edition. 2009. Oxford University Press, New York.
Osborn R, Moulds D, Schneider EC, Doty MM, Squires D, Sarnak DO. Primary care physicians in Ten countries report challenges caring for patients with complex health needs. Health Affairs 34, No 12 (2015): 2104-2112.
Royal College of General Practitioners http://www.rcgp.org.uk/clinical-and -research/a-to-z-clinical-resources/gp-with-a-special-interest-gpwsi- accreditation.aspx accessed, December 18, 2015.
Conflict of Interest:
None declared
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Competing Interests: None declared.