The family doctor in Canada. Part II: entering academia By David Woods people first seriously began to talk about the possi¬ of teaching family medicine as a distinct entity in the medical schools, it became obvious that it would be necessary to discern precisely what it consisted of. Until that time, general practitioners had been educated by acquiring inevitably fragmented knowledge from the various branches of medicine and then fusing it with ex¬
When
bility
perience. When the College of Family Physicians of Canada de¬ veloped its educational objectives program, it set in motion a unique process of definition, since no other medical "specialty" had clearly analysed what it is and does in order that it could be taught in pure form. Traditionally, medical school teaching had been done by specialists a process that tended not only to breed more specialists but to widen the gap between general practitioners and their colleagues in other branches of .
medicine. In Britain, the advent of the National Health Service in 1948 further contrasted the sleek thoroughbred status of the specialist with the workhorse role of the GP by dumping large numbers of patients receiving "free" care on the family doctor. The result of all this, says Dr. Ian McWhinney, the man who eventually occupied the first chair of family medicine to be set up in a North American medical school, was that general practice turned in on itself. General practitioners were forced to look closely and critically at what they were doing and what general practice was all about. Defining it The process of defining the body of knowledge that composes family medicine began as it would in any other discipline: by observing, recording and documenting. Much of the early work was done, oddly enough, by a British psychiatrist, Michael Balint, at London's Tavistock Clinic. In Canada, Drs. Ron McAuley, John Corley, H. C. Still and others were at work on the defining of family medicine in the early 1960s. Dr. McWhinney divides the definition process into three components: values and attitudes; methods and diagnosis, communication and management; and factual knowledge. The first two categories remain fairly constant and pertain to the much-neglected 'arf of medicine. It is in these areas that the family physician has a particularly valuable contribution to make as a teacher. The knowledge component, the science, is a constantly the one that gives rise to all the changing element concern about a medical degree's having a half-life of 5 years and to dire predictions about the GP's being swamped .
234 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
new developments if he doesn't paddle frenetically to reach the shores of medical wisdom. The fact is, of course, that family medicine is still at least as much an art as it is a science. W^hile any professional must keep his eyes, and his books, open and retain his curiosity about new knowledge, the practising GP still uses only 20-30 drugs regularly; he still finds the bulk of his work in relatively unchanging patterns of minor illness. Family medicine, then, is essentially a practical disci¬ pline, and teaching it consists in showing medical students not just how to regurgitate facts but how to use them intelligently. Properly taught, family medicine should also embody a true liberal education: it teaches observation of the human condition in all its forms. Somerset Maugham once said that he found his own medical training to be the perfeet education for a novelist.
by
The new era The two ancient schools of Greek medicine represented, says McWhinney, the reductive, classifying branch and the the latter being the Hippocratic approach, holist one which looked at the illness in the whole individual within his environment. He believes that we are leaving an era of linear, reductive medicine and entering one that adopts the holistic method. This has occurred because we have reached the end of a technological age and arrived at a realization that science does not offer all the answers. This is part of the reason for the renaissance of family med¬
icine. Once
family medicine becomes a branch of the under¬ graduate medical school curriculum, as it did in Canada in 1968 at McMaster and the University of Western Ont¬ it must obviously continue to define and refine its ario content. If it doesn't, the first question that people will ask is: what can you teach that others can't? Residency programs had been under way since 1966 and were instigated by the College of Family Physicians. When the first undergraduate program got under way at Western, it symbolized an academic coming of age. Where do the teachers of family medicine come from? At the University of Western Ontario, there was already a core of general practitioners in the community who were providing students with elective experience in their prac¬ tices. So, in a sense, many of the first teachers in the new department were self-selected. The question of more formal preparation for family med¬ icine teaching can be answered in two ways, says Mc¬ Whinney: there is the reductive approach, systematizing and even standardizing the process. Then there is a second approach in which the teachers are the kinds of physicians .
they are trying to produce. These teachers analyse what they are doing and its effects in a fluid process that involves videotape reviews of their work and students' reactions along with continued dialogue designed to polish and update the technique. Broad exposure The teacher of family medicine is not, however, engaged in a hit-or-miss activity. He must have the knowledge to impart, and he must be able to verbalize his own intellectual processes. Since most of what the family doctor will eventu¬ ally see and have to deal with among his patients occurs outside of the hospital, much of the teaching process conin teaching sists of a broad exposure in the community units, community hospitals and family practices themselves. Then students can learn not just that a patient is acutely depressed but that he can be taught to understand the family and environmental factors leading to his depression. Family practice is the why, as well as the what, of illness. Medicine, especially family medicine, is a craft. It embraces science, art, technology and intuition, and it there¬ fore cannot be learned exclusively from books. Technology is quite unable to produce a violin of the quality of those produced by a half-literate Italian in the 18th century .
.
Stradivarius.
What, then, constitutes the art of medicine (and its ap¬ plication), and can it be taught? Essentially, it is a matter of empathy, understanding and human interaction between doctor and patient, and academics in family medicine be¬ lieve, it can be taught. Today, 15 of Canada's 16 medical schools have depart¬ ments or divisions of family medicine, and such departments have sprung up all over the United States, spurred on by federal funding. Their rapid appearance has created some piracy for the services of the better teachers. What undergraduate programs in family medicine have had to put straight are some of the shibboleths embodied in the Flexner report of 1910.
The report placed medical education under university control, and the learning process was confined mainly to
teaching hospitals where
health problems tended toward the exotic rather than the routine. It took more than half a century for medical education to begin to focus on the walking patient, instead of the 1 in 1000 who entered a
teaching hospital. Mind you, something had to be done about medical education as it was performed in the early part of this century, and in many ways Flexner performed a valuable
service. Horrible
example Many of the US medical schools were profit-making private enterprises with lax entrance requirements and questionable curricula. Flexner found one in Chicago which had "no entrance requirements, no laboratory teaching, no hospital connections", and he further observed that in many schools the professor "is a busy physician or surgeon (who) lectures to ill-prepared students for an hour a few times weekly, in a huge amphitheatre, showing a bone be¬ tween his fingertips or eloquently describing an organ which no one but the prosecutor directly sees; at the close of which oratorical performance he snatches his hat and, amid mingled applause and catcalls, makes for his auto¬ mobile to begin his round of daily visits." While there were at the time some good schools, such as Johns Hopkins, the majority suffered from poor staff and facilities and perhaps even from a tendency to give their students more credit than they deserved. One British physician, visiting the US in the late 19th century, noted an absence of a thorough grounding in the basic medical sciences of anatomy, physiology, pathology and therapeutics, which, he said, were "stagnant backwaters" of the curriculum. In "The General Practitioner", his 1963 study of medical education and general practice, Dr. Kenneth Clute found that Ontario and Nova Scotia GPs generally considered
isafi Holism:
treating
the man,
understanding
the influences
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 235
their traditional medical school training enthusiastically throughout the aca¬ demic world and remain, says Dr. plus a year of rotating internship to be Fallis, "the ultimate standard against inadequate for the realities of actual which our other educational compo¬ practice. nents are measured." Practically all (90.9%) of the reThere are two routes to certification spondents felt that training should in¬ clude preceptorships with a general in family medicine: residency-eligible candidates may take the exam, and practitioner, and nearly half of them considered that more time should be GPs who have spent at least 5 years in spent with hospital outpatients. practice and are members of the col¬ In today's training for family prac¬ lege may also do so. The practising family doctor's learn¬ tice, these needs appear to have been recognized. As Dr. F. B. Fallis, chair¬ ing activity is really a 40-year process. man of the University of Toronto's There is never a point at which he can department of family and community safely feel that he knows it all or even knows enough. medicine, points out: "Certain essential How he goes about ensuring that he ingredients of family medicine should be made available to all undergraduates is reasonably up to date with new medical knowledge and techniques is interviewing, counselling and interpersonal relations, problem-solving in very much a matter of individual taste the primary care setting, family life and, to a degree, of personal discipline; once he leaves the structured educa¬ education, patient and community re¬ tional environment of the medical sponsibilities, family dynamics and a McWhinney: Education fallacies exist whole multitude of facts and minor school, the family doctor is faced with procedural skills." Inculcating all of this, he says, requires tailoring his continuing education to his own needs, the the use of family physician teachers throughout the under¬ time he has available and the methods he finds most instructive and enjoyable. graduate curriculum. Fallis believes that family medicine now enjoys a secure The executive director of the College of Family Physi¬ place in that curriculum, integrating biophysical and clin¬ cians of Canada, Dr. Donald I. Rice, believes the most ical know-how with special relationships to behavioural important element in a continuing education program is science, preventive medicine and community health re¬ "to direct physicians to a study of what they do, to an sources. identification of their own educational deficits and to the establishment of realistic priorities." The college's selfWhat's available evaluation program is an effective means of pinpointing On continuing medical education for family physicians, their deficits and priorities, he says. there is of course an endless array of methods for keeping Rice also feels that CME for family doctors should be up to date: journals, seminars, books, tapes, scientific inexpensive and participatory and allow not only feedback assemblies. And, increasingly, techniques of self-evaluation on the individual's performance but recognition in the form are becoming available as a sort of rustproofing method of diplomas or tax incentives. He stresses that the ultimate for the practitioner. The College of Family Physicians' objective of continuing medical education is higher stand¬ highly successful certification program is a searching and ards of patient care. The patients themselves, Dr. Rice sophisticated test of knowledge and ability. There are those points out, are beginning to demand assurances that doctors who suggest that, without this kind of evidence of con¬ are maintaining standards. And so, beyond natural pro¬ tinuous learning, licences to practise should be withheld. fessional interest in updating knowledge, there's a vested The college itself encourages continuing medical education interest too. Besides the traditional methods of acquiring new knowl¬ by making at least 100 hours of it in each 2-year period a condition of membership. edge and brushing up on the old, such as books and journals But, according to Dr. McWhinney, one must be aware and scientific meetings, there are a number of less obvious of the fallacies in this area, one of which, he says, has educational tools for the GP. to do with the so-called knowledge explosion. If you look Videotape, for example, is just beginning to enjoy recog¬ at how medicine is practised, he says, you will find that nition and wider availability; as family doctors practise medical error is seldom due to the practitioner's not knowing increasingly in groups, coverage of their workload by the, facts; much more often, he believes, it is due to a partners or locums allows them to engage in clinical traineecommunication problem: the physician hasn't listened to ships lasting anywhere from 2 weeks to 6 months. Research the patient, or he has communicated poorly either with in family medicine is gathering momentum (see part III the patient or with other health workers involved. in this series) and offers excellent educational opportunities. To assess the continuing quality of a physician's work And, with the growing number of departments of family by the information he has is too simplistic; the key to a medicine in the universities and family practice units as¬ practitioner's growth as a physician depends on his self- sociated with them, the possibilities for learning by teaching knowledge and capacity to look at himself critically and are developing rapidly. Finally, clinical audit offers a to expose himself to criticism. Once he can do this, there valid and effective means of continued self-learning in is no lack of methods for keeping abreast of medical defamily practice. Both for medical students and for the practising family velopments. The basic practice of medicine does not change that dramatically from year to year. doctors who are the protagonists in this series of articles, Certification formalizes the education process, and well learning is a process quite different from what it was even over 1000 physicians have availed themselves of the a few years ago. examinations to date. Today, family medicine is a definite, teachable discipline, Started in 1969, the certification exams test not only and its practitioners, far from being physicians who have factual recall but practical ability. Using one-way mirrors, "fallen off the ladder of specialization", are specialists in actors playing patients, television interviews and role playtheir own right. ing, the Canadian-developed examinations have been studied In part III of the series.the family physician as an investigator. .
236 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
When
bility
perience. When the College of Family Physicians of Canada de¬ veloped its educational objectives program, it set in motion a unique process of definition, since no other medical "specialty" had clearly analysed what it is and does in order that it could be taught in pure form. Traditionally, medical school teaching had been done by specialists a process that tended not only to breed more specialists but to widen the gap between general practitioners and their colleagues in other branches of .
medicine. In Britain, the advent of the National Health Service in 1948 further contrasted the sleek thoroughbred status of the specialist with the workhorse role of the GP by dumping large numbers of patients receiving "free" care on the family doctor. The result of all this, says Dr. Ian McWhinney, the man who eventually occupied the first chair of family medicine to be set up in a North American medical school, was that general practice turned in on itself. General practitioners were forced to look closely and critically at what they were doing and what general practice was all about. Defining it The process of defining the body of knowledge that composes family medicine began as it would in any other discipline: by observing, recording and documenting. Much of the early work was done, oddly enough, by a British psychiatrist, Michael Balint, at London's Tavistock Clinic. In Canada, Drs. Ron McAuley, John Corley, H. C. Still and others were at work on the defining of family medicine in the early 1960s. Dr. McWhinney divides the definition process into three components: values and attitudes; methods and diagnosis, communication and management; and factual knowledge. The first two categories remain fairly constant and pertain to the much-neglected 'arf of medicine. It is in these areas that the family physician has a particularly valuable contribution to make as a teacher. The knowledge component, the science, is a constantly the one that gives rise to all the changing element concern about a medical degree's having a half-life of 5 years and to dire predictions about the GP's being swamped .
234 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
new developments if he doesn't paddle frenetically to reach the shores of medical wisdom. The fact is, of course, that family medicine is still at least as much an art as it is a science. W^hile any professional must keep his eyes, and his books, open and retain his curiosity about new knowledge, the practising GP still uses only 20-30 drugs regularly; he still finds the bulk of his work in relatively unchanging patterns of minor illness. Family medicine, then, is essentially a practical disci¬ pline, and teaching it consists in showing medical students not just how to regurgitate facts but how to use them intelligently. Properly taught, family medicine should also embody a true liberal education: it teaches observation of the human condition in all its forms. Somerset Maugham once said that he found his own medical training to be the perfeet education for a novelist.
by
The new era The two ancient schools of Greek medicine represented, says McWhinney, the reductive, classifying branch and the the latter being the Hippocratic approach, holist one which looked at the illness in the whole individual within his environment. He believes that we are leaving an era of linear, reductive medicine and entering one that adopts the holistic method. This has occurred because we have reached the end of a technological age and arrived at a realization that science does not offer all the answers. This is part of the reason for the renaissance of family med¬
icine. Once
family medicine becomes a branch of the under¬ graduate medical school curriculum, as it did in Canada in 1968 at McMaster and the University of Western Ont¬ it must obviously continue to define and refine its ario content. If it doesn't, the first question that people will ask is: what can you teach that others can't? Residency programs had been under way since 1966 and were instigated by the College of Family Physicians. When the first undergraduate program got under way at Western, it symbolized an academic coming of age. Where do the teachers of family medicine come from? At the University of Western Ontario, there was already a core of general practitioners in the community who were providing students with elective experience in their prac¬ tices. So, in a sense, many of the first teachers in the new department were self-selected. The question of more formal preparation for family med¬ icine teaching can be answered in two ways, says Mc¬ Whinney: there is the reductive approach, systematizing and even standardizing the process. Then there is a second approach in which the teachers are the kinds of physicians .
they are trying to produce. These teachers analyse what they are doing and its effects in a fluid process that involves videotape reviews of their work and students' reactions along with continued dialogue designed to polish and update the technique. Broad exposure The teacher of family medicine is not, however, engaged in a hit-or-miss activity. He must have the knowledge to impart, and he must be able to verbalize his own intellectual processes. Since most of what the family doctor will eventu¬ ally see and have to deal with among his patients occurs outside of the hospital, much of the teaching process conin teaching sists of a broad exposure in the community units, community hospitals and family practices themselves. Then students can learn not just that a patient is acutely depressed but that he can be taught to understand the family and environmental factors leading to his depression. Family practice is the why, as well as the what, of illness. Medicine, especially family medicine, is a craft. It embraces science, art, technology and intuition, and it there¬ fore cannot be learned exclusively from books. Technology is quite unable to produce a violin of the quality of those produced by a half-literate Italian in the 18th century .
.
Stradivarius.
What, then, constitutes the art of medicine (and its ap¬ plication), and can it be taught? Essentially, it is a matter of empathy, understanding and human interaction between doctor and patient, and academics in family medicine be¬ lieve, it can be taught. Today, 15 of Canada's 16 medical schools have depart¬ ments or divisions of family medicine, and such departments have sprung up all over the United States, spurred on by federal funding. Their rapid appearance has created some piracy for the services of the better teachers. What undergraduate programs in family medicine have had to put straight are some of the shibboleths embodied in the Flexner report of 1910.
The report placed medical education under university control, and the learning process was confined mainly to
teaching hospitals where
health problems tended toward the exotic rather than the routine. It took more than half a century for medical education to begin to focus on the walking patient, instead of the 1 in 1000 who entered a
teaching hospital. Mind you, something had to be done about medical education as it was performed in the early part of this century, and in many ways Flexner performed a valuable
service. Horrible
example Many of the US medical schools were profit-making private enterprises with lax entrance requirements and questionable curricula. Flexner found one in Chicago which had "no entrance requirements, no laboratory teaching, no hospital connections", and he further observed that in many schools the professor "is a busy physician or surgeon (who) lectures to ill-prepared students for an hour a few times weekly, in a huge amphitheatre, showing a bone be¬ tween his fingertips or eloquently describing an organ which no one but the prosecutor directly sees; at the close of which oratorical performance he snatches his hat and, amid mingled applause and catcalls, makes for his auto¬ mobile to begin his round of daily visits." While there were at the time some good schools, such as Johns Hopkins, the majority suffered from poor staff and facilities and perhaps even from a tendency to give their students more credit than they deserved. One British physician, visiting the US in the late 19th century, noted an absence of a thorough grounding in the basic medical sciences of anatomy, physiology, pathology and therapeutics, which, he said, were "stagnant backwaters" of the curriculum. In "The General Practitioner", his 1963 study of medical education and general practice, Dr. Kenneth Clute found that Ontario and Nova Scotia GPs generally considered
isafi Holism:
treating
the man,
understanding
the influences
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 235
their traditional medical school training enthusiastically throughout the aca¬ demic world and remain, says Dr. plus a year of rotating internship to be Fallis, "the ultimate standard against inadequate for the realities of actual which our other educational compo¬ practice. nents are measured." Practically all (90.9%) of the reThere are two routes to certification spondents felt that training should in¬ clude preceptorships with a general in family medicine: residency-eligible candidates may take the exam, and practitioner, and nearly half of them considered that more time should be GPs who have spent at least 5 years in spent with hospital outpatients. practice and are members of the col¬ In today's training for family prac¬ lege may also do so. The practising family doctor's learn¬ tice, these needs appear to have been recognized. As Dr. F. B. Fallis, chair¬ ing activity is really a 40-year process. man of the University of Toronto's There is never a point at which he can department of family and community safely feel that he knows it all or even knows enough. medicine, points out: "Certain essential How he goes about ensuring that he ingredients of family medicine should be made available to all undergraduates is reasonably up to date with new medical knowledge and techniques is interviewing, counselling and interpersonal relations, problem-solving in very much a matter of individual taste the primary care setting, family life and, to a degree, of personal discipline; once he leaves the structured educa¬ education, patient and community re¬ tional environment of the medical sponsibilities, family dynamics and a McWhinney: Education fallacies exist whole multitude of facts and minor school, the family doctor is faced with procedural skills." Inculcating all of this, he says, requires tailoring his continuing education to his own needs, the the use of family physician teachers throughout the under¬ time he has available and the methods he finds most instructive and enjoyable. graduate curriculum. Fallis believes that family medicine now enjoys a secure The executive director of the College of Family Physi¬ place in that curriculum, integrating biophysical and clin¬ cians of Canada, Dr. Donald I. Rice, believes the most ical know-how with special relationships to behavioural important element in a continuing education program is science, preventive medicine and community health re¬ "to direct physicians to a study of what they do, to an sources. identification of their own educational deficits and to the establishment of realistic priorities." The college's selfWhat's available evaluation program is an effective means of pinpointing On continuing medical education for family physicians, their deficits and priorities, he says. there is of course an endless array of methods for keeping Rice also feels that CME for family doctors should be up to date: journals, seminars, books, tapes, scientific inexpensive and participatory and allow not only feedback assemblies. And, increasingly, techniques of self-evaluation on the individual's performance but recognition in the form are becoming available as a sort of rustproofing method of diplomas or tax incentives. He stresses that the ultimate for the practitioner. The College of Family Physicians' objective of continuing medical education is higher stand¬ highly successful certification program is a searching and ards of patient care. The patients themselves, Dr. Rice sophisticated test of knowledge and ability. There are those points out, are beginning to demand assurances that doctors who suggest that, without this kind of evidence of con¬ are maintaining standards. And so, beyond natural pro¬ tinuous learning, licences to practise should be withheld. fessional interest in updating knowledge, there's a vested The college itself encourages continuing medical education interest too. Besides the traditional methods of acquiring new knowl¬ by making at least 100 hours of it in each 2-year period a condition of membership. edge and brushing up on the old, such as books and journals But, according to Dr. McWhinney, one must be aware and scientific meetings, there are a number of less obvious of the fallacies in this area, one of which, he says, has educational tools for the GP. to do with the so-called knowledge explosion. If you look Videotape, for example, is just beginning to enjoy recog¬ at how medicine is practised, he says, you will find that nition and wider availability; as family doctors practise medical error is seldom due to the practitioner's not knowing increasingly in groups, coverage of their workload by the, facts; much more often, he believes, it is due to a partners or locums allows them to engage in clinical traineecommunication problem: the physician hasn't listened to ships lasting anywhere from 2 weeks to 6 months. Research the patient, or he has communicated poorly either with in family medicine is gathering momentum (see part III the patient or with other health workers involved. in this series) and offers excellent educational opportunities. To assess the continuing quality of a physician's work And, with the growing number of departments of family by the information he has is too simplistic; the key to a medicine in the universities and family practice units as¬ practitioner's growth as a physician depends on his self- sociated with them, the possibilities for learning by teaching knowledge and capacity to look at himself critically and are developing rapidly. Finally, clinical audit offers a to expose himself to criticism. Once he can do this, there valid and effective means of continued self-learning in is no lack of methods for keeping abreast of medical defamily practice. Both for medical students and for the practising family velopments. The basic practice of medicine does not change that dramatically from year to year. doctors who are the protagonists in this series of articles, Certification formalizes the education process, and well learning is a process quite different from what it was even over 1000 physicians have availed themselves of the a few years ago. examinations to date. Today, family medicine is a definite, teachable discipline, Started in 1969, the certification exams test not only and its practitioners, far from being physicians who have factual recall but practical ability. Using one-way mirrors, "fallen off the ladder of specialization", are specialists in actors playing patients, television interviews and role playtheir own right. ing, the Canadian-developed examinations have been studied In part III of the series.the family physician as an investigator. .
236 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
