Is family medicine ready to look where it is heading?

Dr Ladouceur is to be commended for his editorial, which opens the door to hard questions for family medicine as a discipline.¹ However, to zero in on Certificates of Added Competence as a part of the problem risks overlooking evidence of a more worrisome problem.

Why are new graduates restricting or focusing their practices? Outside of those working in only emergency medicine (which has been an issue for at least 20 years), there can only be 2 broad categories of reasons: remuneration and satisfaction.

Remuneration, under which I would include the economics of covering inpatients and housecalls, is largely beyond the control of the College. This is to be negotiated between the government and the medical associations (or, increasingly, imposed by provincial ministries).

If new doctors are dissatisfied, it is vital for the College of Family Physicians of Canada to determine the main reasons why, and it needs to be done soon.

Is it the increasing burden on family physicians to care for patients with mental illness, pain, and addictions? That can be addressed in residency and continuing medical education.

Is it the increasing burden on family physicians 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 management²).

However, if 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 human resource–planning systems. If everyone operates under the broad assumption that most family doctors practise family medicine, but new family doctors do not want the job, what will primary care look like in 10 years? Will a full-service family practice be a quaint, romantic ideal for all but the most isolated and devoted practitioners? If that is the case, should the College continue to promote a vision of family medicine that is out of step with huge swaths of its work force? Or should the College take the lead and reinvent the profession, taking a hard look at every now-sacred cow?

Unfortunately, the consequence of inaction is having family medicine defined by specialist whims and government mandates.

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