The family physician

The height of the pinnacle is determined by the breadth of the base.

                                                                         Ralph Waldo Emerson

Leading up to the release of a journal issue, our team scans the publication lineup with the aim of grouping similar pieces in the same month. Take, for example, March’s issue on chronic pain.¹ By curating content related to pain and its management, we were able to provide a sense of thoroughness to the topic at hand. This month, while there is no obvious theme, the material in this issue happens to reflect the breadth and complexity of our work in primary care. Dr Nathanael Turner expands on this idea in his thoughtful essay (page 490).² He describes family medicine as a double-edged sword: “I am awed as I witness the full breadth of medicine but I am daunted in equal measure.” And it is no wonder. Managing a single patient’s multiple diagnoses within their lifetime is not a simple assignment.

Yet in primary care, we perform this integrative task in every patient encounter. After all, the body, when viewed in pieces, does not make sense. Imagine receiving a breast biopsy report indicating grade 2 ductal carcinoma in situ—how does a breast cancer diagnosis map onto our multifaceted patient? (This month’s Oncology Briefs provides a practical tool to help us with such a case [page 473].³) How does this new diagnosis influence the management of our patient’s rheumatoid arthritis and generalized anxiety disorder? How will they cope, having recently separated from their partner? And after supporting this patient through this heaviness, we then open the door to a grinning 6-month-old for a well-baby check. Primary care requires practitioners to be fully present with each patient, but we underestimate the skill and cognitive load of shifting focus multiple times per day.

In a 1936 paper, authors used the term switching cost to refer to the financial cost of switching out a damaged train car from the track.⁴ The term gained traction in the field of economics in the 1980s,⁵ and in more recent decades switching cost has appeared in the psychological literature to describe the cognitive energy required to switch between mental tasks.⁶ This load is felt in patient encounters, when various issues, from trauma to chest pain to diabetes counselling, may occur not only with different patients, but also within a single visit. Providing care based on guidelines is nearly impossible. One study estimated that family physicians would need a total of 21 hours per day in order to accomplish thorough preventive care and manage chronic conditions.⁷ It is not surprising that a recent study found family medicine to be one of the most complex medical disciplines.⁸ Breadth is taxing on the brain.

The aforementioned Emerson quote was written in the 19th century as part of his broader essay on transcendentalism, but it applies to family practice. Does the breadth of our work elevate it, or does generalism render us less valuable? In medical school, the hidden curriculum places family medicine at the very bottom of the academic Jenga stack.⁹ This is reflected in statements about being “just” a family doctor and even in the way that provincial and territorial insurers assign fee codes.¹⁰

At the same time, the value of family physicians is becoming increasingly clear. According to a recent landmark Norwegian study, when general practitioners had long-term relationships with patients, there were lower system costs, less health care use, and increased life expectancies for patients.¹¹ This research has confirmed what we already knew: family medicine is the base of the Jenga tower. Without the breadth of its foundation, the entire medical structure collapses.

And so there is a theme to this issue after all: nothing can be viewed in isolation, whether organs or diseases, information or individuals. As jacks of all trades, we integrate our knowledge and skills in every patient encounter, and we couple that with a deep understanding of the idiosyncrasies of individuals. By seeing the big picture and knowing how the parts fit together, we provide excellent care for our patients. Therein lies ultimate mastery.

• Copyright © 2023 the College of Family Physicians of Canada