Family practice: Professional identity in transition. A case study of family medicine in Canada☆
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
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The authors wish to acknowledge the contribution of Donna Riley, translator and editor, in the preparation of this manuscript for publication.