Family medicine: high standards and high value

What is the primary reason the CFPC exists? Setting and assuring the expectations of what it means to be a family physician. In a word: standards. The CFPC standards functions include accreditation of residency training programs, the Certification Examination in Family Medicine, awarding Certification in the College of Family Physicians of Canada and Certificates of Added Competence, as well as establishing certification and reporting expectations for professional development. Many of our standards relate to residency training, which comes early in our careers. As a result, once you’re in practice, these functions feel less relevant. It raises the question: Why am I paying for that?

Standards establish the quality and credibility of our profession and remind everyone of the value of family medicine. No matter what program you graduate from in Canada, regulators, employers, other medical professionals, and our patients know you have the core knowledge, skills, and abilities to be a family physician. Standards are also the foundation of our excellent international reputation.

However, often the important things are not obvious, and sometimes we take them for granted. Dr Nicholas Pimlott reminded me of David Foster Wallace’s parable from a 2005 commencement address. To paraphrase: 2 goldfish are swimming in their bowl and they come across an older fish. The older fish asks the younger fish, “Hey boys, how’s the water?” then swims off. One of the younger fish turns to the other and says, “What’s water?” Foster Wallace explained it as “the most obvious, important realities are often the ones that are hardest to see.”¹

How are standards—these vital functions of the CFPC and family medicine profession—paid for? Examination fees cover a fair portion of examination expenses, but the majority of costs supporting standards are covered by CFPC members. It can be thought of a bit like an inverted pension: Practising members are investing in their past (residency), and safeguarding the present and future of their profession. Membership fees also support standards through ongoing professional development work and maintaining credentials. The value of credentials is clear but very much takes on the role of the water in Foster Wallace’s story; all around, going unnoticed. How do we then help members remember the importance of that and appreciate the need for member dues to support it? Two things come to mind.

Maybe you wonder if it would be reasonable to have someone else foot the bill? For those who may think residents should pay a greater share, consider this: spread out over 2 years, that would be a heavy cost on those earning the least amount of money and already shouldering high levels of debt. Those in practice continue to benefit from the excellence of these standards, the value of our professional designations, and the comprehensive nature of our training.

If family doctors don’t cover the expenses of standards, who will? Governments? We would be at risk of regulation and external control and no longer be self-governing. The directions of the CFPC do not always seem to make sense, but we are governed by members, collaborate with partners, and adapt to change. Government funding would change that; just think how long we’ve been waiting for the government to act on compensation and system supports concerns.

A key part of our standards functions is defending family medicine excellence and scope of practice. A few years ago, Ontario considered limiting emergency practice to only those with additional training, which would have been a huge blow to family medicine and rural communities. Advocacy by the CFPC, underscored by our standards, allowed family physicians to continue practising in rural and regional emergency departments. Similar pressures are arising again, as governments look for shortcuts to fill gaps in primary care and comprehensive family medicine due to years of poor planning and underfunding. It is our standards and CFPC advocacy that will protect our profession and the health of Canadians. The entire health system depends on family physicians—we provide over half of all health care contacts—and having a family physician is the best predictor of better health outcomes.² To borrow from Foster Wallace’s parable: Family medicine is the water and it is our standards that keep that water flowing.

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