Toward an identity and team-based practice rooted in transdisciplinarity

Value of family medicine training and reasoning

Family medicine is oriented around a generalist philosophy and reasoning.^14,15 Family medicine residency training focuses on acquiring knowledge, skills, and attitudes that integrate biomedical, psychosocial, and biographical understanding, with the goal of providing comprehensive and holistic care to people and populations.¹⁶ Both theory and research highlight the value of family medicine.^17-24 We know that when primary care systems are well-funded and resourced, they lead to better patient outcomes (eg, earlier diagnosis) and reduced costs to health care systems (eg, through fewer visits to emergency departments for advanced illnesses).^17-24 In such settings, family medicine is critical because family physicians are health care professionals who have the training and expertise to diagnose, treat, and manage the greatest breadth of patients across illnesses, lifespans, and care settings.^17-24 Their medical reasoning is particularly essential for effectively diagnosing patients in community settings without excessive use of diagnostic procedures.^17-24 Furthermore, given their unique role as first-contact and continuous person-focused care providers, family physicians have the potential to build long-standing relationships with patients and communities, which can ultimately support patient advocacy, health literacy, and health equity–focused initiatives.²¹ Also, given the unique positionality of family physicians, they are often asked to address the non-medical factors that influence health outcomes (ie, social determinants of health) for patients and communities.²⁵

Value of generalist philosophy and medicine unclear

Despite evidence demonstrating what family medicine is and can be, and what it has done for Canada, systems continue to dismiss generalist medicine and instead add generalist tasks to family physician workloads. For example, in an April 2024 statement from the College of Family Physicians of Canada, it was noted that family physicians spend, on average, 19 hours per week conducting administrative tasks.²⁶ This fact speaks to the devaluation of the expertise that family physicians bring to health systems. Further, this administrative load makes it difficult to sustain the increasingly large rosters that family physicians are required to manage, which are also growing in complexity as populations age and patients experience higher rates of comorbidity. To manage this added complexity, family medicine has repeatedly asked for more resources.²⁷ However, in the past, we have seen that measures such as adding international medical graduates into the system only served as a stopgap.¹ Canadians are struggling to see their family physicians; consequently, they are being referred to specialists at increasing rates and spending hours in emergency departments or urgent care facilities.²⁸

While we are hoping the development of new community-focused medical schools across Canada will help address these issues, the reality is that more than 50% of family medicine graduates are using enhanced skills programs to shift away from practising comprehensive primary care to more focused specialist care.^29-34 Although this might not be premeditated, and might be in response to learning the realities of general practice in the current paradigm, it pushes us to reflect on the fact that simply training more people will not solve our crisis. Unless family physicians are empowered and incentivized to practise holistic and integrative medicine, new trainees will continue to leave comprehensive primary care for higher-paying and more sustainable specialized care positions and restricted practices.

The relevance of family medicine is further undermined as other disciplinary units are developing and scaling large, well-funded multidisciplinary and interdisciplinary units. For example, across North America, we are beginning to see a rise in models of “primary HIV care,” where people living with HIV are able to receive whole-person, continuous, and comprehensive care in a single centre from a multidisciplinary or interdisciplinary team of health care professionals.^35-37 Also, as academics rightfully push for patient-centred care principles to be adopted across disciplinary boundaries (eg, infectious diseases), specialist teams are increasingly improving their ability to provide continuity of care and coordination across care providers.³⁸ The rise in these specialized primary care units is increasing opportunities for patients to receive primary care outside of the more traditional family medicine setting.³⁹ However, it must be made clear that these multidisciplinary and interdisciplinary units are designed to support specialized primary care (ie, continuous, comprehensive, coordinated, and person-centred care for individuals with a particular illness or a specific population, such as those living with HIV). They are not designed to support primary care and well-being across all illnesses and populations.

More alarming than medical systems failing to understand the value of generalist philosophy is the crisis of identity among generalist physicians.⁴⁰ Shah et al, for example, express uncertainty in the animating purpose guiding generalist medicine, alongside “the very nature of what the role of GP [general practitioner] is and of what is needed in order to occupy it.”⁴⁰ Others have identified that across generalist physicians⁴¹ and international undergraduate and postgraduate policy and education mission documents,⁴² a lack of consistent and universal understanding around the distinct expertise of generalist medicine exists. Moreover, we see that a generalist identity can be associated with lower prestige among trainees,⁴³ and that some of the most complex tasks of medicine—“integrating, personalizing, and prioritizing care for whole people”⁴⁴—are often limited to 10 minutes and lead to less compensation than those who are practising narrowly focused technical skills.⁴⁴ To us, these issues serve to reinforce that a professional identity built around generalism is being systematically discredited. Specifically, there is a tension between, on the one hand, the holistic focus and breadth of understanding that a generalist orientation affords family physicians and, on the other, our system’s expressed need for, and valuing of, the establishment of clear role boundaries, which might be in direct conflict with what patients and communities need and value.

Transdisciplinary generalism

To truly express the breadth of care, expertise, and services family medicine affords to systems, a shift toward an identity rooted in transdisciplinary generalism must be made.⁴⁵ Where generalism often refers to a broad array of knowledge and skills, instead of specialization in any particular discipline or domain, transdisciplinary generalism expresses that one is an expert or specialist in synergizing knowledge and skills from across disciplinary boundaries to solve complex and real-world challenges.^45-47 Transdisciplinary generalism is a new way of describing what family medicine practitioners have traditionally done: integrate various biomedical, biographical, and contextual information in their reasoning to provide holistic and comprehensive care.⁴⁵ However, what makes this orientation unique is that it moves away from thinking about family medicine as generalists who develop “mini specializations” or “subspecializations” only after completing additional training.^48,49 This orientation also serves to move generalism away from our traditional paradigm, which operates under a restrictive biomedically focused approach to thinking and practice.⁴⁵ For example, while generalist philosophy recognizes the importance of whole-person care, our current paradigm makes us operate under a model that trains clinicians to think and act as if optimal health and well-being can be effectively achieved through fragmented and disease-centred care. Transdisciplinary generalism, instead, embraces a more flexible, adaptive, and coherent approach toward integrating knowledge from various domains (eg, biomedicine, public health, sociology, psychology, spirituality, ecology, etc) and from patients themselves (ie, relational knowledge stemming from the idea that patients are active protagonists of their health and well-being, not simply recipients of care) to navigate complexity in holistic fashion.⁴⁵ The hope is that by shifting from medical generalism to transdisciplinary generalism, patients, funding bodies, and family physicians themselves will recognize that primary care practitioners are the only professionals trained to think and operate across disciplinary boundaries to deliver whole-person integrated health care, address complexity and social determinants of health, and engage in continuous patient empowerment across illnesses and populations. This could potentially be used to argue for innovating the way we think of our roles and responsibilities in communities (eg, incentivizing time to build networks with community organizations and establishing programs for vulnerable, at-risk, and underserved populations). Table 1 provides further explanation of the differences between generalism and transdisciplinary generalism.

Toward transdisciplinary team care

Beyond encouraging social and structural recognition that family medicine is inherently a transdisciplinary specialty, effort must also be taken to transition multidisciplinary and interdisciplinary teams to transdisciplinary teams.^46,47 Multidisciplinary teams consist of 2 or more clinicians who work together but whose tasks remain within their disciplinary boundaries.^46,47,50 For example, many health care teams involve clinicians from different disciplines (eg, psychology, nutrition, dietetics, nursing, pharmacy, social work, physiotherapy, occupational therapy, medicine) who come together to address the health and well-being of a particular population group.^46,47 In these settings, care providers generally function independently, providing parallel lines of care for patients.^46,47,50 In an interdisciplinary team, clinicians come together to offer integrated service for patients; for example, by working together to develop a joint plan for their patients.^46,47,50 Transdisciplinary teams take interdisciplinary teams a step further by establishing enough trust within the team and by raising capacity across its members to engage in role release and role expansion, allowing others to engage in tasks that are often considered to be under the purview of a specific discipline.^46,47 In this regard, it is critical to know exactly what the roles and responsibilities of each team member are, and which tasks can or cannot be shared. In such teams, hierarchical boundaries across clinical specialties and between clinicians and patients do not exist.⁴⁷ Patients are considered active members of the team, and all team members are respected and valued for the knowledge and skills they bring.⁴⁷ To note, this paradigmatic shift in collaborative practice is not new. Examples of transdisciplinary teams in primary care settings and in settings that integrate primary care with secondary and tertiary settings are on the rise.^51-53 Canada, in this regard, can function as a global leader, especially as it has been a champion thus far for team-based care provision and a pioneer for the Patient’s Medical Home vision.^54,55 Table 2 provides an explanation of the differences between multidisciplinarity, interdisciplinarity, and transdisciplinarity.