Translating gossip into respectful dialogue

As Chair of the Editorial Advisory Board (V.B.), and as Scientific Editor (N.P.) of Canadian Family Physician, we are aware of the concerns regarding Dr Ladouceur’s editorial, “Family medicine is not a business,”¹ and have reflected on the many Rapid Responses to the editorial.^2-4 We wanted to share our reflections through our lenses as practising FPs and researchers.

Dr Ladouceur’s highly provocative (and as many have argued, factually incorrect) title highlights the under-recognized burden of running community-based “businesses” using antiquated funding models. Dr Ladouceur described “gossip” about the handling of uninsured services and the overuse of telemedicine during the pandemic. These are separate but important issues. Their origins are in the outdated, constraining, and inequitable fee structures that most FPs work within, and this is where we should focus our attention. The strain of managing the business of family practice before and during the pandemic has pushed many FPs to burnout.

Behaviour and choices of FPs must be understood in the context of structural influences, and should not be conflated with simplistic characterizations of physicians as ethical versus unethical individuals. Characterizing physicians as good or bad perpetuates a cultural problem in medicine that fails to recognize structural influences on behaviour and in moments of struggle. This hinders our development, both individually and professionally.

The way we talk about professional conduct and choice is critical. Without compassion, we cannot support opportunities for improvement. Polarizing physicians prevents them from cultivating mutual support and compassion, asking for help when overburdened, and discussing lessons learned during times of struggle. Stigmatizing those who have made choices out of self-interest or self-protection does not encourage us to examine the ethical implications of the choices we make in our clinical and practice management roles.

Many choices extend beyond the way that FPs are billing and running their practices, and include other taboo topics related to the business of medicine that require further attention. For example, the tremendous wage discrepancies between FPs and other specialists⁵ raises ethical questions about appropriate profit, values assigned by the same antiquated funding model to other specialties, and roles of professional associations and advocacy among medical disciplines in the preservation of fee structures that maintain these wage gaps.

To discuss taboo subjects, we must avoid polarizing into right and wrong, and neither should we recoil from the premise of “I’m doing the best that I can.” We are all trying our best and generally, in human terms, would benefit from noncritical support to do even better. This is particularly relevant when doing our best includes making potentially unethical choices, simply because our professional culture causes us to develop workarounds for immense structural constraints and pressures by pushing ourselves and not recognizing our struggles.

In a master’s thesis,⁶ one of us (V.B.) described entrenched institutional practices and cultures that pressure health care workers to fit the mold of the system, thereby normalizing dysfunction. The impetus for change then falls upon health care workers to either compensate for the broken system or to challenge it. Not recognizing the effect of structural influences on medical practice, including that of dysfunctional structures on workers, reinforces a pathologizing approach in which people, rather than the system, are seen as broken. Thus, we must redirect our energy and dialogue toward difficult conversations about system reform. How we talk about professional conduct, choice, and ethics is important. Gossip can perpetuate stigma and exclusion, so how can we translate gossip into respectful dialogue?

Structures that preserve editorial independence, if not appropriately stewarded, can preserve uncontested privilege of expression, but if appropriately stewarded, can invite engagement and elevate dialogue. When something is questioned by our colleagues, what should we do? Shifting away from unrealistic goals of perfection would be supportive, and we need to build dialogue. When engagement is strong, the opportunity for constructive dialogue emerges. We hope we can adopt this direction as a profession.

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