Where is family medicine heading?

Thank you, Dr Ladouceur, for pointing out the elephant in the room. Hopefully your editorial will stimulate an active and productive discussion within the discipline of family medicine and the College of Family Physicians of Canada.¹

Family medicine has been coasting on a reputation based on principles (see Dr Michael Kidd’s Dr Ian McWhinney Lecture in the same issue of Canadian Family Physician²) 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.³ As hospital stays become shorter and more focused, and more home care becomes necessary, it is particularly concerning that fewer new family medicine graduates see doing home visits 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.”⁴

The issue of whether the development and expansion of Certificates of Added Competence is creating more focused practices or whether they are a response to larger social and system pressures is an important one to address. Currently 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 the shift is driven more by lifestyle and economic considerations rather than the needs of the community.

In the United Kingdom, general practitioners with special interests must continue to maintain a general practice while taking referrals from their colleagues.⁵ The “expert-generalist” is a role that has particular application in rural areas, where access to specialty care is often limited.⁶ 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, Canadian physicians with special interests 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 before Certification. Gérvas and colleagues outline important questions about special-interest general practitioners that need to be addressed.⁷ 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.⁸ 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 reported that Canadian family physicians felt underprepared to manage care of patients in their practices with dementia (42% felt prepared), who required palliative care (42% felt prepared), and with multiple chronic conditions (70% felt prepared).⁹ 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. Generalist family physicians are the most important innovation health care has to offer patients with multiple chronic conditions.

Dr Beaulieu and colleagues have documented that family medicine is in the midst of an identity crisis.¹⁰ As McWhinney said: “Family physicians may be differentiated, but family medicine should not fragment.”¹¹ 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.

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