Getting beneath the surface of things

Every once in a while I get stuck when writing an editorial. Sometimes it is because there is no obvious theme or through-line in the content of the journal, although our team diligently tries to identify one for each issue. More often it is simply because I am stuck on the surface of things.

For this issue of Canadian Family Physician I want to draw attention to 2 articles—Dr Kendall Noel’s commentary on what he calls the “post-examination surprise” (page 533)¹ and Dr Marie-Dominique Beaulieu’s inspirational keynote from Family Medicine Forum in Montréal, Que, in November 2023 on what makes family physicians essential elements of a “good” health care system (page 530).²

As I spent almost a full day reflecting, staring at the blank page, I thought about American sportswriter Red Smith’s reply to an interviewer when asked if writing a daily column was a chore: “Why, no. You simply sit down at the typewriter, open your veins, and bleed.”³ It occurred to me that what both authors have in common is the desire to go well beneath the surface of things, a trait I hope characterizes us as family physicians.

Many family medicine teachers will have experienced the post-examination surprise—the shock we feel when the results of College of Family Physicians of Canada certification examinations come back and we learn that a highly capable resident has failed. In more than 3 decades of teaching, I know I certainly have, and on more than 1 occasion. But in our busy lives we tend to shrug it off, attribute it to the individual having had a bad day, and focus on helping them pass the next examination and trying to restore some of their lost self-confidence.

But what prompted Dr Noel to pay greater attention to it? To want to understand more fully what was going on? In his case it was the drive to make sense of a series of observations showing that some highly competent residents and practice-eligible general practitioners fail the simulated office oral portion of the examination. Encouraged and supported by mentors such as Drs Carlos Brailovsky, Paul Rainsberry, and Judith Belle Brown, it led to a PhD thesis and research findings that I hope will inform the way we evaluate family doctors in the future.

In a time of crisis and upheaval in family medicine, when family physicians are in short supply and when politicians and policy-makers look to replace us in some of our roles with other types of health care providers such as pharmacists and nurse practitioners, many of us ask ourselves: What is unique about what family doctors do that makes us valuable to our patients and to the system? What prompted Dr Beaulieu to reflect deeply about her experiences as a family physician, researcher, and scholar and turn them into her wonderful keynote address? I believe in her case, like Dr Noel’s, it was trying to uncover the unique essence of family physicians that makes them indispensable to high-functioning primary care systems.

When I first heard Dr Beaulieu’s address to a full convention hall last November, there was a frisson of excitement and recognition that we hope to share with readers by publishing it here.

Beneath the Surface of Things is also the title of a recently published and brilliant essay collection by anthropologist Wade Davis,⁴ which I just finished reading a few weeks ago and whose title inspired my editorial. In these challenging times, as family doctors, as teachers of family medicine, and as citizens, it has never been more important to look beneath the surface of things.

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