The family doctor in Canada evolves By David Woods In this, the first of a series of eight articles on family practice, David Woods, former editor of Canadian Family Physician, traces the evolution of the GP from the 17th century English apothecaries to the "specialized" family practitioner of today. Future articles will be devoted to an analysis of the modern GP in his various professional activities.learning, earning, researching, practising and joining (or ignoring) the organizations that represent his interests. Reprints of the series will be available from the CMA depart¬ ment of communications, Box 8650, Ottawa K1G 0G8.
The remarkable thing about the evolution of general prac¬ is tice in Europe, North America and elsewhere that this branch of medicine is alive and well in the 1970s despite innumerable predictions of its imminent extinction. The story of general practice, then, is one of resilience and survival, and also, to a degree, of history's repeating itself: the general practitioner's training, his role, his re¬ are all even his title lationships with specialists current concerns, but they were voiced in the 19th century and even earlier. So a review of family medicine in Canada today needs as its backdrop an historical survey. Even though there were clear distinctions between physi¬ cians and surgeons in Aristotle's time, the whole business of who did what was quite confused in Europe right up to the 1890s. In England, the apothecaries, who were really the progenitors of today's GP, were pharmacists who practised medicine: in the 17th century the physicians were the equivalent of today's specialists using the apothecary, in the words of one history book, as "the practitioner of first instance; but very rudely because the patients were not seen." The apothecaries rose from being shopkeepers to being fullblown medical practitioners who dispensed their own medicines. Also, until the early 19th century, barbers and surgeons had an uneasy formal alliance, and barbers were still permitted by law to practise surgery. Even worse, there was very little regulation of qualifications or licensing in any of the branches of medicine. Although the apothecary was supposed only to dispense, not prescribe: to be what one practitioner called "the physician's cooke", it was during the Great Plague of London in 1664-65 that apothecaries gained the right to treat patients. It was really a case of having to, since most of the physicians had fled the city. The great landmark in the history of the general practi¬ tioner is the Apothecaries Act of 1815. The act tightened licensing requirements and officially sanctioned the practice of medicine by apothecaries. It required candidates to have served an apprenticeship of not less than 5 years, to be "of good moral character" and to take an exam in pharma.
.
92 CMA JOURNAL/JANUARY 11, 1975/VOL. 112
ceutical chemistry and the theory and practice of medicine but not in surgery or midwifery. The act also forbade sur¬ geons to dispense prescriptions. By 1829, the apothecaries were allowed to charge not only for the medicine they prescribed but for the medicine they practised. And it was at about this time that they began to be known as general practitioners. The transformation was commented upon enthusiastically by the forthright editor of The Lancet, Thomas Wakley: "General practitioners," he wrote, "will no longer be regarded in families as plunderers, whose interested object is to convert the stomachs of their patients into drug shops, but they will now be looked upon as men of experience and skill, and their ability to prescribe appropriate remedies for diseases will be valued rather more highly than their ability to mix those remedies in a bottle or in a mortar."
Men of all work
Wakley didn't care much for the name general prac¬ as a "monstrous" title for men of learning and character and noting scornfully that "men of all work" would not be a whit more absurd or irrational. Wakley's concern for semantics may have been based on the observations of an anonymous "member of the University of Oxford" who had written, some years before, that Edinburgh-trained doctors were "rabble", moreover, that surgeons and apothecaries were gentlemen but there would have to be a lower order, general practitioners, to fulfil the lower duties. And, on the subject of terminology, Sir George Clark, in his "History of the Royal College of Physicians of London" notes that "the family physician enjoyed a higher scale of remuneration (in the 19th century) than the general practitioner." In London, says Clark, all physicians retained a certain portion of family practice; there were no exclusively consultant practices. It is interesting that during this period, too, a college of general practitioners was first mooted: while a Metro¬ politan College was founded, it faded quickly and today's Royal College of General Practitioners wasn't formed until 1952, a mere 2 years before the Canadian one. In fact, the general practitioner existed in North Amer¬ ica before he came into being in Europe. At least in name. But
titioner, describing it
Colonial
necessity "In the rugged and mobile society of the colonies," says Dr. Ian McWhinney, professor of family medicine at the University of Western Ontario, "it was not possible for any group of practitioners to confine their work to one specialty; they were obliged by circumstances to practise both medicine and surgery and to dispense drugs." Before the first Canadian medical schools were set up in Montreal and Toronto in 1823 and 1853 respectively,
country's practitioners were immigrants (as large number today) or had served an apprenticeship. Many of Canada's early practitioners were naval or military surgeons, and, while these were probably quite well trained according to the knowledge and standards of the day, there were some pretty doubtful physicians at large. In his paper on the history of medicine in Canada, given before the Royal College of Surgeons of London in 1966, Robert Swan said that, despite a 1790 law requiring proper licensing of doctors in Canada, quackery continued to flourish. He quotes a Kingston, Ont., newspaper as denouncing "those who, without one ray of science, presume to thrust the created into the presence of their creator." However, things began to improve. The Ontario Licensing most of the are a
very
Acts of 1815 and 1819 decreed that physicians would have before they could get a licence. And the
to pass an exam
patient's lot became a happier one. Prognosis
poor But before the end of the 19th century the GP's role and future were already becoming topics of pessimistic speculation. In 1892, none other than Sir William Osler predicted the general practitioner's eventual disappearance. He felt that, in urban areas at least, patients would seek out the specialist. In a sense, Osler was right: from the time the Royal College of Physicians and Surgeons of Canada was founded in 1929 and began to standardize specialist training and certification, the trend towards specialization gathered momentum. That momentum has slowed only in very recent years. Specialization, of course, existed in Canadian medicine well before the beginning of this century. Robert Swan speculates that an ophthalmologist from London's Moorfields Hospital was the first on the specialist scene in Canada. An appropriate discipline when one considers the number of occasions subsequently GPs and specialists have not seen eye to eye with each other. Although, as Dr. Irwin Bean, head of the department of family medicine at Toronto's Wellesley Hospital, told the annual meeting of the College of Family Physicians of Canada last September: "Family practice is the oldest of all medical specialties." Bean described the acceptance by the medical profession of the royal college as "somewhat less than enthusiastic",
^R
noting that by the end of 1930 a mere 22 members had availed themselves of fellowship. If the specialists were largely unimpressed with their own organization when it was formed, North American GPs were none too happy when specialists, albeit unorganized ones, first came along in the 1850s. Reaction
General practitioners, says William G. Rothstein in his book "American Physicians in the Nineteenth Century", reacted to specialization in U.S. medicine "much as they had responded to sales of secret nostrums by physicians," and some of them even tried to have specialists barred from the AMA and ostracized by the profession. The basis of GPs' anger was that, in their view, speciali¬ zation could lead to a heedless neglect of general medicine; they were especially concerned about the increasing tend¬ ency of younger physicians to specialize before they had become competent general practitioners. More practically, the proliferation was beginning to hurt general physicians financially: specialists were getting more cases and higher fees, and they were also heaven forbid advertising. Perhaps the biggest rift in the GP-specialist relationship came with the Flexner report in 1910. This resulted in medical education's being placed under the university's control in the milieu of the teaching hospital. In Canada, as in many other countries, medical educa¬ tion has tended, at least until very recently, to be dominated by specialists. Centring it in the teaching hospital served to ignore ambulatory, community health problems to a large degree and made for the production of more specialist and hospital-oriented doctors. The whole question of the GP's role in the hospital has been a sore point, too. The general practitioner needs such a role not only for the purpose of admitting his patient but also for providing continuity of care. Further, the hospital serves as an ideal meeting place for the pooling of ideas among all branches of the medical and allied health professions. In 1957, the Builetin of the then College of General Practice of Canada (at that time a mere 3-year-old) pub¬ lished a Bill of Rights for GPs. It included the rights to perform in hospital any procedures or services of which they were capable, to admit patients to hospital on an equal opportunity basis with specialist confreres; and to admit to hospitals where they were not necessarily on the active staff. The following year, the college made hospital integration of the GP the major theme of its annual convention. The college's first executive director, Dr. W. Victor Johnston, reported in 1959: "The position of the general practitioner in some city general hospitals continues to give the college much concern.. there still remain too many hospitals where they are denied participation in staff or¬ .
.
ganizations."
Dr. Johnston concluded: "The college is now able to demonstrate that full integration of the GP (into the hospital) is highly desirable to all concerned." .
No
Good medical
care came
gradually
sooner
..
said
...
Desirable or not, something must have happened to change the situation. Dr. Kenneth F. Clute, in his exhaustive 1963 study of medical education and practice in Ontario and Nova Scotia, "The General Practitioner", summed up the GP-hospital relationship he encountered: "A minority of the doctors in each of the two provinces commented on the matter of hospital restrictions, and only about 10% in each province made comments that showed CMA JOURNAL/JANUARY 11, 1975/VOL. 112 93
Early GPs got plenty of fresh air any antipathy to the hospitals' policies in this regard." Clute said he did not think the charges that GPs were being excluded from hospitals had any basis in fact, except, possibly, in the case of the teaching hospitals. While there is not quite as much uncertainty today about which branches of medicine are supposed to provide what services certainly not as much as in the days of the apothecaries there is still some confusion. If the trend towards specialization that reached its peak in the 1960s has indeed begun a downhill turn, there remain doubts and debates about who exactly is the physician of first contact. One of the difficulties Clute encountered was the fairly basic one of even defining a general practitioner; finally, faced with the array of specialists who were providing at least some primary care, he decided to include in his GP category those physicians who were spending at least half their working time in primary practice. Today's concern of the family physician that pediatricians, for example, should stick to their specialty and not simply be "GPs for little people" has its roots in the rancorous debates between specialists and generalists in the second half of the 19th century. .
THE HOLLISTER DRAINING-WOUND
MANAGEMENT SYSTEM KEEPS FLUIDS AWAY FROM PATIENTS SKIN AND GUARDS AGAINST IRRITATION AND CONTAMINATION. Odor-barrier, translucent Drainage Collector holds exudate for visual assessment and accurate measurement. There are no messy, wet dressings to handle. View wound through Access Cap. Remove cap for wound examination and drain tube adjustment. There is no need for painful dressing removal. Supplied sterile, for application in O.R. or patient's room. The better alternative to absorbent dressings.
B HOLLISTER Wrtte for more information.
Hollister Ltd., 332 Consumers Rd.,
Willowdale, Ont. M2J 1 P8
94 CMA JOURNAL/JANUARY 11, 1975/VOL. 112
The
more
things change
...
Then, as now, a large part of the issue has to do with status. For years, the general practitioner was considered to be someone who had fallen off the ladder of specializa¬
tion: a second-class citizen in the clearly staked-out medical territories. Two comparatively recent events which have helped to improve the GPs' status were the founding of the Col¬ lege of General Practice in 1954 and the advent of medicare in Canada in the mid- and late 60s. Clute found that GPs in his 1963 survey expressed the hope that the college would "stick up for their rights" both in the hospitals, if "state medicine" came and just gen-
- such as they were - and liberal erally. One respondent even urged that doses of friendly, personal care, the the college do something to cut down GP's stock-in-trade. In his first year of the number of early deaths among genmedical practice he earned well under eral practitioners. $2000. So far as status was concerned, those In his years of practice, Dr. Johnston questioned looked to the college for saw little or no diphtheria, rickets, improvements of their prestige with the scurvy or typhoid fever. But whooping public and with the specialists, for incough, mumps and pneumonia were creased standards of general practice, common,andnothingcouldbe done for involvement in medical teaching and about them - there were no antibiotics, for the engendering of greater mutual no penicillin, no cortisone. Insulin was respect between specialists and generaldiscovered only 2 years before Johnston ists. set up his practice in Lucknow, Ont. Although it is difficult to assess what Dr. Johnston admits that the general the college has been able to do for the practitioner's image "declined steadily" Canadian GP's life expectancy, it has through the 1930s to the 1950s, until certainly upgraded standards and status the point was reached, he says, "at and, in the process, worked some pretty which the respected and beloved family impressive alchemy: today's general doctor of old was becoming in the eyes practitioner/family physician is, in fact, of the public a professional incoma specialist. petent." The effect of medicare on general Part of the problem, of course, lay in practice was to alert governments to the enormous task of trying to keep the higher costs of primary care given Osler GP will disappear up with the phenomenal increases in by specialists and to the importance of medical knowledge; it became clear to Johnston and others nreventive medicine. that something would have to be done about the GP's As Brian Inglis points out in his "History of Medicine": continuing education. "Only by a return to the family doctor, old style, who knew And so the college was formed with 400 members (and his patients and their circumstances (and not just their $10000 from the CMA) in 1954. symptoms), could the appropriate preventive measures be Since that time, it has been able to implement measures taken." that have not only given a new status to Canadian general Rebirth practitioners but established a leadership role for Canada One of the old style family doctors who helped to bring in developing a new model of family physician: a prototype about this renaissance in Canada was William Victor Johnfor providing personal, comprehensive and continuing care ston, the first executive director of the college. within the family and community setting. Starting out as a country practitioner in 1924, before the age of miracles (the title, incidentally, of his memoirs), David Woods' next article in the series will deal wi*h the training of the family physician. Johnston offered his patients the fruits of medical science MEDICAL SERVICES continued from page 88 CMA's computer terminals as part of an ongoing review of what the association's department of research and development can contribute to the work of the Council on Medical Services. The CMA rents time on the Ottawa University computer and stores documents and information in it. This information is instantly available and a cross-indexing system enables documents on any subjects to be immediately identified.
Computer editing Dr. J. F. Brandejs, head of R and D, said the council can use the computer for preparation and storage of its documents. After a document has been stored in the computer, word changes and other editing can be carried out without the need for retyping. When the final version has been agreed on, the operator can press the appropriate button and out comes a perfectly typed copy. Dr. J. G. Mills, council chairman, reported on a visit to Europe he undertook on a World Health Organization grant. He studied the health care sys-
tems of several European countries, including that of Britain where, he told the council, more and more incentive fees now are being provided to physicians in addition to the capitation fees on which the National Health Service was originally based. Dr. Mills will present a full, written report shortly. Council member Dr. W. L. Davis is preparing a position paper on the primary care physician. A first draft has been circulated and Dr. R. F. Fairbairn provided some comments. Dr. Davis asked for further comments within three weeks so he can prepare the final copy by the March meeting of the council. Dr. Mills said a study in London, Ont., shows a fairly large proportion of specialists do provide primary care and consider this their normal role. In a discussion on the semantics of the issue,
Th. .or. tM.k .J
).4z .
of O.awa h. the Ioa Qt .tropertics
council members decided that care provided by a health professional should actually be named tertiary care; primary care should be the name used for the care a person provides for himself and secondary care could be used to describe care provided by family members. The Council on Medical Services considered the subject of medical services in penitentiaries. This was a followup to a seminar on "correctional medicine" at the OMA annual meeting in Toronto, June 1974. Name wrong Council members decided that correctional medicine is not a good name for the particular activity. Furthermore boarding schools, old people's homes and many other institutions have similar health care features, the chief one being some degree of restriction in choice of medical practitioner. The seminar at the annual meeting was part of a joint effort by the CMA, and federal and Ontario governments to improve medical care of prisoners. Those attending voted to ask the association to explore ways of improving standards. J. G.
CMA JOURNAL/JANUARY 11, 1975/VOL. 112 95
The remarkable thing about the evolution of general prac¬ is tice in Europe, North America and elsewhere that this branch of medicine is alive and well in the 1970s despite innumerable predictions of its imminent extinction. The story of general practice, then, is one of resilience and survival, and also, to a degree, of history's repeating itself: the general practitioner's training, his role, his re¬ are all even his title lationships with specialists current concerns, but they were voiced in the 19th century and even earlier. So a review of family medicine in Canada today needs as its backdrop an historical survey. Even though there were clear distinctions between physi¬ cians and surgeons in Aristotle's time, the whole business of who did what was quite confused in Europe right up to the 1890s. In England, the apothecaries, who were really the progenitors of today's GP, were pharmacists who practised medicine: in the 17th century the physicians were the equivalent of today's specialists using the apothecary, in the words of one history book, as "the practitioner of first instance; but very rudely because the patients were not seen." The apothecaries rose from being shopkeepers to being fullblown medical practitioners who dispensed their own medicines. Also, until the early 19th century, barbers and surgeons had an uneasy formal alliance, and barbers were still permitted by law to practise surgery. Even worse, there was very little regulation of qualifications or licensing in any of the branches of medicine. Although the apothecary was supposed only to dispense, not prescribe: to be what one practitioner called "the physician's cooke", it was during the Great Plague of London in 1664-65 that apothecaries gained the right to treat patients. It was really a case of having to, since most of the physicians had fled the city. The great landmark in the history of the general practi¬ tioner is the Apothecaries Act of 1815. The act tightened licensing requirements and officially sanctioned the practice of medicine by apothecaries. It required candidates to have served an apprenticeship of not less than 5 years, to be "of good moral character" and to take an exam in pharma.
.
92 CMA JOURNAL/JANUARY 11, 1975/VOL. 112
ceutical chemistry and the theory and practice of medicine but not in surgery or midwifery. The act also forbade sur¬ geons to dispense prescriptions. By 1829, the apothecaries were allowed to charge not only for the medicine they prescribed but for the medicine they practised. And it was at about this time that they began to be known as general practitioners. The transformation was commented upon enthusiastically by the forthright editor of The Lancet, Thomas Wakley: "General practitioners," he wrote, "will no longer be regarded in families as plunderers, whose interested object is to convert the stomachs of their patients into drug shops, but they will now be looked upon as men of experience and skill, and their ability to prescribe appropriate remedies for diseases will be valued rather more highly than their ability to mix those remedies in a bottle or in a mortar."
Men of all work
Wakley didn't care much for the name general prac¬ as a "monstrous" title for men of learning and character and noting scornfully that "men of all work" would not be a whit more absurd or irrational. Wakley's concern for semantics may have been based on the observations of an anonymous "member of the University of Oxford" who had written, some years before, that Edinburgh-trained doctors were "rabble", moreover, that surgeons and apothecaries were gentlemen but there would have to be a lower order, general practitioners, to fulfil the lower duties. And, on the subject of terminology, Sir George Clark, in his "History of the Royal College of Physicians of London" notes that "the family physician enjoyed a higher scale of remuneration (in the 19th century) than the general practitioner." In London, says Clark, all physicians retained a certain portion of family practice; there were no exclusively consultant practices. It is interesting that during this period, too, a college of general practitioners was first mooted: while a Metro¬ politan College was founded, it faded quickly and today's Royal College of General Practitioners wasn't formed until 1952, a mere 2 years before the Canadian one. In fact, the general practitioner existed in North Amer¬ ica before he came into being in Europe. At least in name. But
titioner, describing it
Colonial
necessity "In the rugged and mobile society of the colonies," says Dr. Ian McWhinney, professor of family medicine at the University of Western Ontario, "it was not possible for any group of practitioners to confine their work to one specialty; they were obliged by circumstances to practise both medicine and surgery and to dispense drugs." Before the first Canadian medical schools were set up in Montreal and Toronto in 1823 and 1853 respectively,
country's practitioners were immigrants (as large number today) or had served an apprenticeship. Many of Canada's early practitioners were naval or military surgeons, and, while these were probably quite well trained according to the knowledge and standards of the day, there were some pretty doubtful physicians at large. In his paper on the history of medicine in Canada, given before the Royal College of Surgeons of London in 1966, Robert Swan said that, despite a 1790 law requiring proper licensing of doctors in Canada, quackery continued to flourish. He quotes a Kingston, Ont., newspaper as denouncing "those who, without one ray of science, presume to thrust the created into the presence of their creator." However, things began to improve. The Ontario Licensing most of the are a
very
Acts of 1815 and 1819 decreed that physicians would have before they could get a licence. And the
to pass an exam
patient's lot became a happier one. Prognosis
poor But before the end of the 19th century the GP's role and future were already becoming topics of pessimistic speculation. In 1892, none other than Sir William Osler predicted the general practitioner's eventual disappearance. He felt that, in urban areas at least, patients would seek out the specialist. In a sense, Osler was right: from the time the Royal College of Physicians and Surgeons of Canada was founded in 1929 and began to standardize specialist training and certification, the trend towards specialization gathered momentum. That momentum has slowed only in very recent years. Specialization, of course, existed in Canadian medicine well before the beginning of this century. Robert Swan speculates that an ophthalmologist from London's Moorfields Hospital was the first on the specialist scene in Canada. An appropriate discipline when one considers the number of occasions subsequently GPs and specialists have not seen eye to eye with each other. Although, as Dr. Irwin Bean, head of the department of family medicine at Toronto's Wellesley Hospital, told the annual meeting of the College of Family Physicians of Canada last September: "Family practice is the oldest of all medical specialties." Bean described the acceptance by the medical profession of the royal college as "somewhat less than enthusiastic",
^R
noting that by the end of 1930 a mere 22 members had availed themselves of fellowship. If the specialists were largely unimpressed with their own organization when it was formed, North American GPs were none too happy when specialists, albeit unorganized ones, first came along in the 1850s. Reaction
General practitioners, says William G. Rothstein in his book "American Physicians in the Nineteenth Century", reacted to specialization in U.S. medicine "much as they had responded to sales of secret nostrums by physicians," and some of them even tried to have specialists barred from the AMA and ostracized by the profession. The basis of GPs' anger was that, in their view, speciali¬ zation could lead to a heedless neglect of general medicine; they were especially concerned about the increasing tend¬ ency of younger physicians to specialize before they had become competent general practitioners. More practically, the proliferation was beginning to hurt general physicians financially: specialists were getting more cases and higher fees, and they were also heaven forbid advertising. Perhaps the biggest rift in the GP-specialist relationship came with the Flexner report in 1910. This resulted in medical education's being placed under the university's control in the milieu of the teaching hospital. In Canada, as in many other countries, medical educa¬ tion has tended, at least until very recently, to be dominated by specialists. Centring it in the teaching hospital served to ignore ambulatory, community health problems to a large degree and made for the production of more specialist and hospital-oriented doctors. The whole question of the GP's role in the hospital has been a sore point, too. The general practitioner needs such a role not only for the purpose of admitting his patient but also for providing continuity of care. Further, the hospital serves as an ideal meeting place for the pooling of ideas among all branches of the medical and allied health professions. In 1957, the Builetin of the then College of General Practice of Canada (at that time a mere 3-year-old) pub¬ lished a Bill of Rights for GPs. It included the rights to perform in hospital any procedures or services of which they were capable, to admit patients to hospital on an equal opportunity basis with specialist confreres; and to admit to hospitals where they were not necessarily on the active staff. The following year, the college made hospital integration of the GP the major theme of its annual convention. The college's first executive director, Dr. W. Victor Johnston, reported in 1959: "The position of the general practitioner in some city general hospitals continues to give the college much concern.. there still remain too many hospitals where they are denied participation in staff or¬ .
.
ganizations."
Dr. Johnston concluded: "The college is now able to demonstrate that full integration of the GP (into the hospital) is highly desirable to all concerned." .
No
Good medical
care came
gradually
sooner
..
said
...
Desirable or not, something must have happened to change the situation. Dr. Kenneth F. Clute, in his exhaustive 1963 study of medical education and practice in Ontario and Nova Scotia, "The General Practitioner", summed up the GP-hospital relationship he encountered: "A minority of the doctors in each of the two provinces commented on the matter of hospital restrictions, and only about 10% in each province made comments that showed CMA JOURNAL/JANUARY 11, 1975/VOL. 112 93
Early GPs got plenty of fresh air any antipathy to the hospitals' policies in this regard." Clute said he did not think the charges that GPs were being excluded from hospitals had any basis in fact, except, possibly, in the case of the teaching hospitals. While there is not quite as much uncertainty today about which branches of medicine are supposed to provide what services certainly not as much as in the days of the apothecaries there is still some confusion. If the trend towards specialization that reached its peak in the 1960s has indeed begun a downhill turn, there remain doubts and debates about who exactly is the physician of first contact. One of the difficulties Clute encountered was the fairly basic one of even defining a general practitioner; finally, faced with the array of specialists who were providing at least some primary care, he decided to include in his GP category those physicians who were spending at least half their working time in primary practice. Today's concern of the family physician that pediatricians, for example, should stick to their specialty and not simply be "GPs for little people" has its roots in the rancorous debates between specialists and generalists in the second half of the 19th century. .
THE HOLLISTER DRAINING-WOUND
MANAGEMENT SYSTEM KEEPS FLUIDS AWAY FROM PATIENTS SKIN AND GUARDS AGAINST IRRITATION AND CONTAMINATION. Odor-barrier, translucent Drainage Collector holds exudate for visual assessment and accurate measurement. There are no messy, wet dressings to handle. View wound through Access Cap. Remove cap for wound examination and drain tube adjustment. There is no need for painful dressing removal. Supplied sterile, for application in O.R. or patient's room. The better alternative to absorbent dressings.
B HOLLISTER Wrtte for more information.
Hollister Ltd., 332 Consumers Rd.,
Willowdale, Ont. M2J 1 P8
94 CMA JOURNAL/JANUARY 11, 1975/VOL. 112
The
more
things change
...
Then, as now, a large part of the issue has to do with status. For years, the general practitioner was considered to be someone who had fallen off the ladder of specializa¬
tion: a second-class citizen in the clearly staked-out medical territories. Two comparatively recent events which have helped to improve the GPs' status were the founding of the Col¬ lege of General Practice in 1954 and the advent of medicare in Canada in the mid- and late 60s. Clute found that GPs in his 1963 survey expressed the hope that the college would "stick up for their rights" both in the hospitals, if "state medicine" came and just gen-
- such as they were - and liberal erally. One respondent even urged that doses of friendly, personal care, the the college do something to cut down GP's stock-in-trade. In his first year of the number of early deaths among genmedical practice he earned well under eral practitioners. $2000. So far as status was concerned, those In his years of practice, Dr. Johnston questioned looked to the college for saw little or no diphtheria, rickets, improvements of their prestige with the scurvy or typhoid fever. But whooping public and with the specialists, for incough, mumps and pneumonia were creased standards of general practice, common,andnothingcouldbe done for involvement in medical teaching and about them - there were no antibiotics, for the engendering of greater mutual no penicillin, no cortisone. Insulin was respect between specialists and generaldiscovered only 2 years before Johnston ists. set up his practice in Lucknow, Ont. Although it is difficult to assess what Dr. Johnston admits that the general the college has been able to do for the practitioner's image "declined steadily" Canadian GP's life expectancy, it has through the 1930s to the 1950s, until certainly upgraded standards and status the point was reached, he says, "at and, in the process, worked some pretty which the respected and beloved family impressive alchemy: today's general doctor of old was becoming in the eyes practitioner/family physician is, in fact, of the public a professional incoma specialist. petent." The effect of medicare on general Part of the problem, of course, lay in practice was to alert governments to the enormous task of trying to keep the higher costs of primary care given Osler GP will disappear up with the phenomenal increases in by specialists and to the importance of medical knowledge; it became clear to Johnston and others nreventive medicine. that something would have to be done about the GP's As Brian Inglis points out in his "History of Medicine": continuing education. "Only by a return to the family doctor, old style, who knew And so the college was formed with 400 members (and his patients and their circumstances (and not just their $10000 from the CMA) in 1954. symptoms), could the appropriate preventive measures be Since that time, it has been able to implement measures taken." that have not only given a new status to Canadian general Rebirth practitioners but established a leadership role for Canada One of the old style family doctors who helped to bring in developing a new model of family physician: a prototype about this renaissance in Canada was William Victor Johnfor providing personal, comprehensive and continuing care ston, the first executive director of the college. within the family and community setting. Starting out as a country practitioner in 1924, before the age of miracles (the title, incidentally, of his memoirs), David Woods' next article in the series will deal wi*h the training of the family physician. Johnston offered his patients the fruits of medical science MEDICAL SERVICES continued from page 88 CMA's computer terminals as part of an ongoing review of what the association's department of research and development can contribute to the work of the Council on Medical Services. The CMA rents time on the Ottawa University computer and stores documents and information in it. This information is instantly available and a cross-indexing system enables documents on any subjects to be immediately identified.
Computer editing Dr. J. F. Brandejs, head of R and D, said the council can use the computer for preparation and storage of its documents. After a document has been stored in the computer, word changes and other editing can be carried out without the need for retyping. When the final version has been agreed on, the operator can press the appropriate button and out comes a perfectly typed copy. Dr. J. G. Mills, council chairman, reported on a visit to Europe he undertook on a World Health Organization grant. He studied the health care sys-
tems of several European countries, including that of Britain where, he told the council, more and more incentive fees now are being provided to physicians in addition to the capitation fees on which the National Health Service was originally based. Dr. Mills will present a full, written report shortly. Council member Dr. W. L. Davis is preparing a position paper on the primary care physician. A first draft has been circulated and Dr. R. F. Fairbairn provided some comments. Dr. Davis asked for further comments within three weeks so he can prepare the final copy by the March meeting of the council. Dr. Mills said a study in London, Ont., shows a fairly large proportion of specialists do provide primary care and consider this their normal role. In a discussion on the semantics of the issue,
Th. .or. tM.k .J
).4z .
of O.awa h. the Ioa Qt .tropertics
council members decided that care provided by a health professional should actually be named tertiary care; primary care should be the name used for the care a person provides for himself and secondary care could be used to describe care provided by family members. The Council on Medical Services considered the subject of medical services in penitentiaries. This was a followup to a seminar on "correctional medicine" at the OMA annual meeting in Toronto, June 1974. Name wrong Council members decided that correctional medicine is not a good name for the particular activity. Furthermore boarding schools, old people's homes and many other institutions have similar health care features, the chief one being some degree of restriction in choice of medical practitioner. The seminar at the annual meeting was part of a joint effort by the CMA, and federal and Ontario governments to improve medical care of prisoners. Those attending voted to ask the association to explore ways of improving standards. J. G.
CMA JOURNAL/JANUARY 11, 1975/VOL. 112 95
