Elsevier

Social Science & Medicine

Volume 67, Issue 7, October 2008, Pages 1153-1163
Social Science & Medicine

Family practice: Professional identity in transition. A case study of family medicine in Canada

https://doi.org/10.1016/j.socscimed.2008.06.019Get rights and content

Abstract

With increasingly fewer family physicians in many countries and students less interested in primary care careers, generalists are becoming an endangered species. This situation is a major health care resource management challenge. In a rapidly changing health care environment, family medicine is struggling for a clear identity—a matter which is crucial to health system restructuring because it affects the roles and functioning of other professions in the system. The objective of our study was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian medical school faculties of medicine, using both focus groups and individual interviews. In addition to family medicine, we targeted residency programs in general psychiatry, radiology and internal medicine—three areas that interface significantly between primary care and specialized medicine. In each faculty, respondents included the vice-dean of postgraduate studies; the director of each relevant program; educators in the program; residents in each specialty in their last year of training. Findings are centred around three major themes: (1) the definition of family medicine; (2) family medicine as an endangered species, and (3) the generation gap between young family physicians and their educators. The sustained physician–patient relationship is considered a core characteristic of family medicine that is much valued by patients and physicians—both generalists and specialists—as something to be preserved in any model of collaboration to be developed. Overall, two divergent directions emerge: preserving all the professions' traditional functions while adapting to changing contexts, or concentrating on areas of expertise and moving towards creating “specialist” general practitioners, in response to a rapidly expanding scope of practice, and to the high value attributed to specialization by society and the professional system.

Introduction

What is a family physician/general practitioner?1 Paradoxically, in an era when the primary care sector is at the heart of most industrialized countries' efforts to reform health care, health care managers, decision-makers, patients and professionals are struggling with this question more than ever. The proportion of general practitioners is not increasing as much as the proportion of specialists in most OECD countries (Organisation for Economic Co-operation and Development, 2007). Students' diminishing interest in primary care careers has been documented in the United Kingdom, Canada and the United States (Bowler and Jackson, 2002, Rosser, 2002, Sox, 2003). Due to factors such as career choices and reduced working hours, some OECD countries are experiencing a relative shortage of primary care physicians, particularly Canada, Australia and the United States (Simoens & Hurst, 2006). A growing proportion of general practitioners are restricting their practice, which diminishes access to primary care providers, particularly in rural and remote regions. For example, in Canada 20% of family physicians polled in the 2007 National Physician Survey planned to limit their scope of practice in the coming year (National Physician Survey, 2007). This phenomenon is also emerging in France (Levasseur & Schweyer, 2005) and Belgium (Diliège, 2004). Trends towards increased specialization, when some OECD countries are promoting a primary care-driven health care system, have become a major challenge of health care resource management (Simoens & Hurst, 2006).

Some argue family physicians' traditional large scope of practice is unrealistic in an era when knowledge is growing exponentially. One response to this challenge, the development of the so-called “specialized family physician,” seems particularly attractive not only to a new generation of family physicians, but also to some health care managers and administrators (Green and Fryer, 2002, Rosser, 2002, Soulier et al., 2006). Indeed, in the United Kingdom, proposals to foster the development of careers as specialist general practitioners have been put forward by the National Health System and the Royal College of General Practitioners (Department of Health & RCGP, 2002). In response to the perceived decreased interest in general practice and the pressure on general practitioners to specialize, pleas to define the discipline better have been made in many countries by family physicians themselves (Graham et al., 2002, Kamien, 2002, Olesen et al., 2000, Wun, 2002). Many general practice organizations have revisited their definition of the discipline (College of Family Physicians, 2004, Future of Family Medicine Project, 2004, Wonca Europe, 2002). However, these new definitions have not achieved unanimous acceptance and many tensions within the discipline persist (Bailey, 2007, Green and Fryer, 2002, Heath and Evans, 2000).

It is widely recognized that developments in primary care call for new, more comprehensive models of professional practice in which, to ensure optimal use of available expertise, professional roles must adapt. Nurses, pharmacists and other health professionals must assume more responsibilities, taking on certain roles that have traditionally been the domain of the family physician (Romanow, 2002, Tyrell and Dauphinee, 1999). Boundaries between professional jurisdictions are thus subject to continued re-negotiation. In a rapidly changing health care environment, family medicine is struggling for a clear identity (Green and Fryer, 2002, Stein, 2006, Stevens, 2001).

The question of professional identity is not insignificant. Professionals need a clear sense of their profession's identity and area of expertise to function effectively (Abbott, 1988). This is crucial to successful system restructuring, because how family physicians define their roles will have a real impact on the roles and functioning of other professionals in the system. To date, this question has not received the attention it deserves and there has been little empirical research into family physicians' representations of their roles in the health care system. In the United States, seven national family medicine organizations launched, in 2002, the Future of Family Medicine Project. Interviews and focus groups were conducted with family medicine trainees and practitioners, as well as specialist physicians and consumers, to explore the core values of family medicine in the United States (Graham, Bagley, Kilo, Spann, & Bogdewic, 2004). The results highlighted that neither the general public nor the professionals had a clear understanding of what family medicine represents. There was significant variance in practice scope among family physicians. Making family medicine an attractive career option was perceived as a challenge. In France, a qualitative study in which 23 general practitioners were interviewed revealed that many questioned the social and intellectual value of their profession in a health care system that highly values technology and specialization (Soulier et al., 2006). In the United Kingdom, Jones and Green (2006) reported shifting discourses of the representations of 20 early career general practitioners, characterized by what the authors called a “new general practice” that explicitly rejects many traditional values, such as the vocational aspect of the discipline. Contrary to many other studies, the authors reported the expression of a high degree of job satisfaction in their respondents.

We report the results of a study whose objective was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian faculties of medicine. We targeted this population because, in health, the educational system plays an important role in developing professional identity (Abbott, 1988, Bucher and Stelling, 1977, Freidson, 2001, Shapiro, 1978), and the apprenticeship model used in medical training significantly affects how physicians internalize professional roles (Bucher and Stelling, 1977, Shapiro, 1978).

Section snippets

Primary care in Canada

In 1984 the Canada Health Act set the ground rules for what was to become the Canadian health care system. The Act guarantees to Canadians universal and free access to “medically required” services provided by physicians and hospital services. Most primary care services are provided by family physicians who operate as independent practitioners and bill directly to the state authority under a fee-for-service system. About 40% of these are solo practitioners. Only 6% of family practices employ

Purpose and objectives of the study

For the purposes of our study, we turned to Canada's medical schools. We wanted to find out how two different sub-groups of the profession—leaders who occupy positions in academic medicine and future family physicians reaching the end of their training—perceive the role of family medicine. We also wanted to explore their ideas about issues such as scope of practice, pressures towards specialization, relationships with patients, societal expectations and other sources of professional tension. To

Design and study population

This is a case study based on a multiple-case design (Yin, 1994), each “case” being a medical school. There are 17 medical schools distributed in Canada's five regions. Some are strongly oriented towards community practice and primary care, while others are more oriented towards specialized care and research. We wanted to contrast the cases on these two characteristics, since data suggest that medical schools' missions may be associated with the careers chosen by their graduates (Bland et al.,

Findings

Participation in the study was broad-based and comprehensive. All the vice-deans of graduate studies and all the program directors (with the exception of two in radiology) participated. Table 1 summarizes the characteristics of the respondents and Table 2 describes the distribution of the respondents according to the type of interviews.

Our findings are reported here according to three major themes: (1) what is a family physician?; (2) family medicine as an endangered species; and (3) the

Discussion

Our data confirm that the profession of family medicine in Canada is going through an evolution and a self-examination that touches specifically upon the systemic boundaries of its identity: the “irritants” of others' perceptions; the practices of specialists; the generation gap; training that occurs particularly in the university hospital setting (with its technologies and accent on specialization); and the development of knowledge. We believe Luhmann's (2004) theory based on the legal

Conclusion

In summary, we observe that, strictly in terms of interprofessional relations, general practice in Canada is in a difficult position, interfacing with several health professions. This central role is also a vulnerable position, since it is subject to the influence of all the subjective and objective changes that define the other professions and set their boundaries. While there are multiple tensions within the profession (in particular, among young physicians who seek to balance quality of life

References (53)

  • A. Abbott

    The system of professions: An essay on the division of expert labor

    (1988)
  • T. Bailey

    Is family medicine a specialty?

    Canadian Family Physician

    (2007)
  • M.-D. Beaulieu et al.

    General practice as seen through the eyes of general practice trainees: a qualitative study

    Scandinavian Journal of Primary Health Care

    (2006)
  • C.J. Bland et al.

    Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature

    Academic Medicine

    (1995)
  • I. Bowler et al.

    Experiences and career intentions of general practice registrars in Thames deaneries: postal survey

    British Medical Journal

    (2002)
  • R. Bucher et al.

    Becoming professional

    (1977)
  • Canadian Institute for Health Information

    Health care in Canada 2003

    (2003)
  • M.L. Cogan

    Toward a definition of profession

    Harvard Educational Review

    (1953)
  • M. Cohen et al.

    Health care system reform: Ontario family physicians' reactions

    Canadian Family Physician

    (2001)
  • College of Family Physicians of Canada

    Family medicine in Canada—vision for the future

    (2004)
  • R.H. Coombs

    Mastering medicine

    (1978)
  • Department of Health et al.

    Implementing a scheme for general practitioners with special interests

    (2002)
  • D. Diliège

    Des médecins Belges parlent de leur métier

    Cahiers de Sociologie et de Démographie Médicales

    (2004)
  • J.M. Feron et al.

    GPs working in solo practice: obstacles and motivations for working in a group? A qualitative study

    Family Practice

    (2003)
  • G.K. Freeman et al.

    Continuity of care: an essential element of modern general practice?

    Family Practice

    (2003)
  • E. Freidson

    Profession of medicine

    (1970)
  • E. Freidson

    Professionalism, the third logic: On the practice of knowledge

    (2001)
  • Future of Family Medicine Project Leadership Committee

    The future of family medicine: a collaborative project of the family medicine community

    Annals of Family Medicine

    (2004)
  • R. Graham et al.

    Report of the task force on patient expectations, core values, reintegration, and the new model of family medicine

    Annals of Family Medicine

    (2004)
  • R. Graham et al.

    Family practice in the United States: a status report

    Journal of the American Medical Association

    (2002)
  • L.A. Green et al.

    Family practice in the United States: position and prospects

    Academic Medicine

    (2002)
  • O. Hall

    The stages of a medical career

    American Journal of Sociology

    (1948)
  • O. Hall

    Types of medical career

    American Journal of Sociology

    (1949)
  • L.R. Harrold et al.

    Knowledge, patterns of care, and outcomes of care for generalists and specialists

    Journal of General Internal Medicine

    (1999)
  • I. Heath et al.

    The specialist of the discipline of general practice

    British Medical Journal

    (2000)
  • S. Horrocks et al.

    Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

    British Medical Journal

    (2002)
  • Cited by (64)

    • Moving towards a contemporary chiropractic professional identity

      2020, Complementary Therapies in Clinical Practice
      Citation Excerpt :

      Within the literature on the practice of family medicine, for example, at least three models have been discussed ranging from: a holistic biopsychosocial orientation that cares for the under-served; a pragmatic approach that considers market forces and personal practice styles; and family medical practitioners acting as gatekeepers for specialty care referral [17]. Within family medical practice, two distinct divergent approaches have been identified with potential future implications on the profession: The ‘generalist’ works to preserve traditional functions while adapting to changing contexts with a large SCOP compared with the ‘specialist’ that concentrates on increasing specialisation amongst general practitioners [7]. This differentiation is said to be the result of a rapidly expanding scope of practice, as well as the high value attributed to specialisation from society and the professional system [7].

    • Professional identity in community care: The case of specialist physicians in outpatient services in Italy

      2019, Social Science and Medicine
      Citation Excerpt :

      Traditionally, the medical profession has built its identity and identification codes around specialised knowledge, the highest expression of which is the development of hospital systems. This particular process has led both patients and health workers to consider hospital doctors as the bearers of “true knowledge” and community and family physicians as the “bureaucratic” maids of the system (Beaulieu el al., 2008; Manca et al., 2008). In a hospital environment, professionals and patients experienced the medical competencies as hierarchically sequential and often separated by precise boundaries (Liberati et al., 2016; Powell and Davies, 2012).

    View all citing articles on Scopus

    The authors wish to acknowledge the contribution of Donna Riley, translator and editor, in the preparation of this manuscript for publication.

    View full text