Wanting family medicine without primary care

Over the past decade, more and more medical students have matched to family medicine.¹ The prevailing mantra is that this trend is unquestionably good. More medical students matching to family medicine means more physicians practising primary care. Having more primary care physicians is better for the health care system. The problem is that some medical students who match to family medicine have no intention of practising primary care.²

Family medicine is pitched to medical students with some of the following points: residency is only 2 years, jobs are available across Canada, and graduates can shape their practices.^3,4 It is that last point that really attracts students to family medicine even if they do not have an interest in primary care.

At the Medical Student and Family Medicine Resident Networking Luncheon at the 2016 Family Medicine Forum in Vancouver, BC, I overheard residents explicitly telling medical students that they could do whatever they wanted with a CCFP designation. If they wanted to do just sports medicine, they could do just sports medicine. If they wanted to do just emergency medicine, they could do just emergency medicine.

Some medical students enter family medicine residency as a backdoor way to pursue their desired specialty. I had an elective student in clinic who wanted to match to dermatology; and he knew that if he did not match to dermatology, he could match to family medicine and pursue a focused practice in dermatology. He is not alone. In a 2009 survey of medical students at Western University in London, Ont, 35% of students interested in the Royal College of Physicians and Surgeons of Canada emergency medicine fellowship program said they intended to apply to family medicine as a backup. The study authors suggested that, based on these results, there was the potential that students were matching to family medicine with no intention of pursuing general practice.²

The interest in focused practices continues even after the medical students enter residency. At a Section of Communities of Practice in Family Medicine (CPFM) networking breakfast at Family Medicine Forum, newly minted residents were already approaching section members to ask how they too could have a focused practice.

In the 1999–2000 fiscal year, Ontario Health Insurance Plan data showed that 54% of the family physicians with emergency medicine Certification from the CFPC derived less than 10% of their annual patient volume from scheduled family practice visits. Fifty-six percent of the family physicians with emergency medicine Certification said they were practising “almost all” or “mostly” emergency medicine. Those physicians were likely to be younger than those practising mostly nonemergency medicine or almost no emergency medicine.⁵

Publicly, the CFPC promotes the idea that the scope of practice in family medicine can be as much or as little as physicians want. On its website, the CFPC notes that it is the “professional home for family physicians who provide comprehensive, continuing care to their patients as well as family physicians who focus some or all of their practices in certain domains of care.”⁶

There is now an entire generation of family medicine residents who entered residency on the premise that they could pursue as narrow and focused a practice as they wanted. Of course, not all residents want a focused practice, but some do. Those residents matched to family medicine without ever intending to practise primary care, seemingly with the blessing of the CFPC. However, these residents are going to be surprised to learn what the prevailing opinion about focused practices actually is within the CFPC.

While the CFPC might publicly promote focused practices, they certainly do not do so privately. It has been my experience that committee and council members of the CFPC have a strong commitment to generalism, and only generalism. Endorsing focused practices during meetings inevitably leads to comments during breaks about the erosion of generalism within family medicine and concern for the future of the profession. Even at sessions by the Section of CPFM, arguably the most pro–focused practice body at the College, many section members preface their public statements with a remark about their commitment to generalism or note that their focused practice is firmly rooted in generalism.

As a resident, I think it is unfair to enter family medicine on a promise from the CFPC to be able to have a focused practice, but then face resistance from the CFPC for choosing a focused practice. There is more at stake than my sense of fairness.

The CFPC can publicly endorse but privately disapprove of focused practices for only so long. There is inevitably going to be a situation where the interests of generalism and the interests of focused practices cannot be reconciled. When that situation comes, the CFPC is going to isolate a large part of its membership, whether it sides with generalism or focused practices.

In my opinion, the CFPC has 2 main options. It can fully accept that some family physicians have focused practices, or it can wholly commit to generalism.

Fully accepting focused practices means fully welcoming physicians with focused practices into the College, not just into the CPFM. Physicians with focused practices should be welcome on various committees and councils, even the education ones that influence the development of future family physicians. Most important, these physicians should not be shamed at CFPC meetings for having focused practices.

Accepting focused practices means a fundamental shift in how family medicine has traditionally been defined. No longer will family medicine be defined by comprehensiveness and breadth of knowledge. This change will get a lot of push back from physicians who believe in family medicine as it is.

On the other hand, committing to generalism means formalizing a generalist definition of family medicine. It also means using all the College’s tools to enforce that definition. The CFPC could go so far as to restrict continuing professional development availability only to physicians who practise comprehensive medicine.

Enforcing a definition of generalism means that some family physicians with focused practices will leave the College. They will find themselves closer to the Royal College of Physicians and Surgeons of Canada than to the CFPC.

The CFPC’s decision is time sensitive. Every year, more and more medical students match to family medicine with the intention of pursuing a focused practice. If the CFPC is going to commit to generalism, it needs to do so now. Physicians with focused practices will continue to grow, especially as more Certificates of Added Competence are approved. If the CFPC waits long enough, eventually, it will be the generalists who seem out of place.

• Copyright© the College of Family Physicians of Canada