The family doctor in Canada. Part V: practising numbers By David Woods As patterns of disease and mortality have changed dramaover the past few decades, so too have the style and content of general practice. Consider, for example, that such scourges as tuberculosis, diphtheria, whooping cough, measles and pneumonia, which once occupied so much of the GP's time, have now virtually been eradicated. While these may have been replaced to some extent by the so-called diseases of choice obesity, alcohol and drugrelated problems, and venereal diseases, for instance the stock-in-trade of today's family doctor, like that of his predecessors, is still the treatment of minor illness and injury. As one GP puts it: "the daily routine of coughs and sniffles, sore throats and scratches". Even though such factors as the advent of formal res¬ idency and undergraduate training programs in family medicine, certification, more open hospital privileges, medi¬ care, patient mobility, urbanization and public demand have all served to alter the face of general practice, there seems to be no real consensus about how primary care is actually being provided in this country or how it should be. Echoing Mark Twain's contention that there are lies, damn lies and statistics, College of Family Physicians' Exe¬ cutive Director Donald Rice has urged that the present statistical information about primary care physicians is "woefully inadequate", not to mention unreliable. The reason for this, as he sees it, is that the reporting agencies use different definitions and criteria, and no al¬ lowance is made for the fact that many specialists are engaged in primary care while some GPs spend much of their time in special interest areas such as anesthesia. Further, some physicians who have become certificants in family medicine are listed as specialists, and others, such as Rice himself, may be included in the GP totals even though they are no longer in medical practice but
tically
.
are
full-time administrators.
In other words, there's a lot of rather arbitrary categorizing and this tends not only to cloud the current physician manpower situation in Canada but to hamper any serious efforts to project future needs. Those needs will not be met simply by taking the number of physicians assumed to be providing primary care and dividing it into total population. Sensible forecasts of health care personnel requirements will stem from some clearer answers to questions about what services will be provided in the future, who is best equipped to provide them, what curbs on MD immigration will do to medical manpower and its distribution, what causes attrition from general practice to the specialties, should pediatricians be allowed 634 CMA JOURNAL/MARCH 8, 1975/VOL. 112
to function as "general practitioners for little people". Answers to these and other questions will depend not only on having reliable data immediately at hand, but also on our arriving at some measure of agreement about
whether the health care vehicle needs as the plethora of recent reports and commissions suggests a complete and radical overhaul or just a good lube job. So far as the existing manpower statistics are concerned, there are discrepancies; nonetheless, the figures are worth looking at because they do point up the complexities of the manpower issue. They also illustrate the differences in practice in our 10 provinces, although they don't really explain them. The College of Family Physicians claims a total of 12 922 family doctors in Canada. Health manpower at Health and Welfare Canada lists 13 333 active physicians in general and family practice (noting, incidentally, that some 4305 of these are foreign graduates; this fact will have to be taken into account in planning for the future if recently proposed legislation to curb MD immigration to Canada is passed). And the Canadian Medical Directory tape shows 12 781 general practitioners. The figures quoted are for 1972, and the problem is further compounded, for here we are into 1975 with no apparent means of judging how many GPs have traded patients for paperwork and moved into administration or other nonpractice endeavours during the past 3 years. In this connection, though, the CMD tape does tell us there are 1690 physicians in Canada who are not engaged in private practice. It is hard to tell whether these are specialists or GPs. Further, we know there are almost 6000 interns and residents, but, again, the tape doesn't indicate what these MDs will actually wind up doing or where they will do it. Perhaps the crystal ball will always be a bit cloudy, and it is possible we should draw such comfort and conclusions as we reasonably can from the facts we do have. In any event, CMD does have something to say about the ratios of family practitioners to specialists in each of the prov¬ inces. Roughly speaking, Newfoundland, Prince Edward Island and Saskatchewan have about 40% more GPs than specialists; Quebec about 40% more specialists than GPs, and in the remaining provinces the ratio is about even. All sides equal In fact, Canada, in contrast with the United States, managed to retain an almost equal split between specialists and general practitioners during the years 1968 fo 1972, although what percentage of each group is actually in full-
time medical practice is questionable. In the US, the GPto-specialist ratio has almost reversed itself over the past 40 years going from 83.5%: 16.5% in 1931 to 25.6%: 74.4% in 1971, according to the American Medical Asso¬ ciation. This may be accounted for, in some measure, by the differences in US and Canadian health care. Perhaps the only truly satisfactory way to acquire ac¬ curate data is to put tabs on all medical school graduates. In this way medical educators and health planners can have some hard facts to work with. Two PhDs, Noralou P. Roos and David G. Fish, fol¬ lowed the careers of the 1128 students who entered Cana¬ dian medical schools in 1965 and were able to track the subsequent careers of 97% of this group. They found that 47% were in general or family practice, 10% had left residency training for general practice and 8% had left general practice for residency training. Roos and Fish also discovered that the output of general practitioners varies enormously among the 12 medical schools studied, ranging from 25% at McGill to 68% at Dalhousie. This information should be of particular interest to both planners and educators, but those faced with the unenviable task of projecting provincial needs will be in¬ terested in the Roos-Fish findings in the matter of aggre¬ gate net gains or losses of the general practitioners in their study: these show Saskatchewan and Manitoba with ap¬ proximately 50% losses, all other provinces with a net loss, and only British Columbia with a net gain a rather substantial 126%.
Will
more
one,
No more guessing All of which suggests that, unpalatable though it may seem, future medical manpower planning will be based less on a laissez faire, even an intuitive, basis and more on the specialty and geographic needs of whatever health care system Canada decides to adopt. And it will begin at the medical school entrant level. It is arguable of course that governments have no busi¬ ness determining who practises what brand of medicine and where; however it is also quite clear that those picking up a $7 billion annual bill for health will expect some say in the matter. As an example, Ontario's minister of health, Frank Miller, who presides over an annual health budget of $2.3 billion and who was instrumental in drafting the proposals to restrict physician immigration, has talked about this chequerboard of Canadian MD manpower and how the pieces on it might be moved. Miller has referred to what he called an "interesting suggestion" that all medical graduates be required to serve as general practitioners in remote areas of the country before embarking on specialist courses. This, he says, is an example of the many methods we may have to consider "to rationalize the situation". Dr. Andrew T. Hunter, a London, Ont. family physician who served on the Ontario Council of Health's task force on manpower, believes that this approach used in parts of Scandinavia and in South Africa results in poor care because the drafted MDs are simply "spinning their wheels" until they can go where they really want to. If statistics about GP-to-specialist ratios are misleading, so are the often-quoted figures on numbers of physicians to
population.
The World Health Organization has decreed that a ratio of one MD to about 650 people is ideal, and Canada surpassed that optimum figure in 1973 with a ratio of 1:618. But, as we have seen, there is absolutely no point in the patient's taking his ingrown toenail to a neurosurgeon
or
his
might
basket.
MDs volunteer for underserviced areas, as did this will remote control acquire new meaning?
or
sore
not
throat to
recognize
a
a
physician-turned bureaucrat.
tonsil if
one
He turned up in his In
2000 to 1 And so, the real ratio of active primary care physicians to population may be something like 1:2000, and it's that kind of workload which may be having a disastrous effect on quality of care, professional satisfaction, and could be contributing to attrition from the general practitioner's ranks. In a 1973 article in the Journal of Medical Education, "The vanishing practitioner", Dr. Edward B. Harvey, pro¬ fessor and chairman of sociology in education at the On¬ tario Institute for Studies in Education (OISE), along with his colleague Dr. A. Hunter, looked closely at this matter of attrition. The respondents to their survey listed long hours, low prestige, too broad a spectrum of problems, difficulties in keeping abreast of new knowledge and inadequate hospital privileges as the major reasons for leaving general practice and entering a specialty. Asked about their medical school training, the GPs departing the field of primary care seemed to feel that they should have had more instruction in dealing with common ailments and other typical general practice situations; some felt they should have been exposed to greater numbers of GP teachers, while others expressed the view that a family doctor needs a more extensive training in psychiatry and in "how to manage human relationships with patients". In looking at these dropout rates the question, it seems to me, is not "Whither the GP?" but "Wither the GP?" Dr. Harvey questions: "If patterns of attrition from gen¬ eral practice are not reversed, and there seems little likelihood they will be, what means exist for alleviating resulting problems in effective health care delivery?" The point raised time and again in the discussion of who does what in medicine, and, to a lesser extent, of where is it done is that existing measurements are pretty crude. CMA JOURNAL/MARCH 8, 1975/VOL. 112 635
If the people who go into general practice find they are unsuited to it and gravitate to a specialty, this is surely a situation that could have been headed off by earlier, fuller knowledge of the aspirant GP and by proper career coun¬ selling. On the other hand, those who leave general practice because of the state of general practice itself (rather than their own condition) and who are concerned about hospital and educational facilities or inadequacies in their own training are the people for whom the College of Family Physicians should be doing its damnedest. If I have dwelt on this question of manpower it is be¬ cause, next to the changes in disease itself, the present and future numbers and distribution of family doctors will have the biggest impact on future primary care practice. Political forces
However, in any discussion of family practice one cannot
ignore the political forces presumably continue to do wonder why, if it is indeed
that
so.
and will shape it Many practitioners must .
true that Canada has one of health care systems in the if not the best the best world, there have been so many recent reports urging extensive changes to that system. While a torrent of suggestions pours forth from Lalonde, Mustard, Pickering, Hastings, Foulkes et al about what should be done to change and improve the system, the practising physician is made to look exaggeratedly con¬ servative and resistant to innovation because he's not quite sure which hoop to jump through; so, often, he decides not to jump at all. To use another analogy, the medical profession has heard the words 'on your marks' and 'get set'; but it has not yet heard the starter's gun. As an example of what I mean, there has already been some consensus among both health planners and practising physicians that the concept of the nurse practitioner is a worthy one. The newly qualified family doctor entering practice might well ask himself: "Where is the team? the nurse Where are all these allied health professionals practitioner especially that I've been expecting to work with?" At present, only McMaster University and the University of Alberta are producing nurse practitioners, and as yet there appears to be no formal mechanism for paying for even though use of the NP represents their services an economy in overall medicare costs. Dr. Donald Rice has expressed real concern about this agreement on the need for change not being followed up by change itself. "Family physicians", he says, ". find themselves in a position of wanting to practise the kind of medicine that the public seems to need and want, and find their hands are tied because the practice community is not yet ready to support this kind of practice. In their frustra¬ tion, a growing number are settling into that familiar pattern of volume practice, an adequate income, less and less professional satisfaction, ultimate disenchantment with family practice, and are finally vacating the discipline for other professional endeavours." Much the same confusion prevails in the matter of whether and how the GP should be involved in health maintenance and preventive medicine. Federal Minister of Health and Welfare Marc Lalonde, in his "New Perspective on the Health of Canadians" strongly urges: Patient, heal thyself. The question is, how? The family doctor with a couple of thousand patients on his books may have some enthusiasm for preventive .
.
.
636 CMA JOURNAL/MARCH 8, 1975/VOL. 112
..
medicine, but he simply may not have the time to do it properly; moreover, the missionary work in this field can be pretty frustrating. As Dr. James Wood, a Saskatoon family doctor with a particular interest in this subject, told me: "We've all been somewhat discouraged in our ability to persuade patients to stop smoking or to lose weight." Nonetheless, Wood believes that the GP has a part to play in identifying risk factors for, say, coronary artery disease; in taking advantage of the undoubted opportunity, though, he must have the cooperation of the patient. Proper preventive medicine, Dr. Wood contends, must be preceded by education of the public so that patients understand the need for a positive approach to health; so they work in partnership with their doctor, seeing him not just for individual episodes of disease but also occasionally when they're well. Whatever the rewards and frustrations of general prac¬ tice, there seems little doubt that governments and public alike want the family doctor. As the Ontario Council of Health noted in its 1974 report on physician manpower: "The primary or first contact physician should be the general practitioner. The specialist's services are more ef¬ fective medically, and more economic, when he concentrates on his specialized skills. Hospital facilities should continue to be available to general practitioners for the care and treatment of their patients." The council urged that the College of Family Practice (sic) and the various specialist societies determine appro¬ priate workloads for GPs and specialists in order that some estimates of future manpower needs can be arrived at. Certainly, as Dr. Donald Rice has put it, the time is now and the hour is late and the troops are getting restless so far as shaping the future of general practice is con¬ cerned. Going further, the Millis commission ("Graduate Education for General Practice" 1967) called for "a revolu¬ tion, not a few patchwork adaptations" to overcome existing disadvantages in general practice. The commission saw three major reasons for a decline in general practice: diminished prestige of this branch of medicine; limited educational opportunities, and conditions of practice that are less attractive than those enjoyed by the specialists. Clearly, family medicine, if it is to develop as an im¬ portant specialty in its own right, must be more than a stop-gap measure to relieve the crisis in primary care. The family physician, as defined by the American Medi¬ cal Association, is "one who practises in the discipline of family practice and whose training and experience qualify him to practise in several fields of medicine and surgery with particular emphasis on the family unit." The AMA goes on to state that the FP also serves the public as the physician of first contact and means of entry to the health care system; evaluates his patient's total health assumes responsibility for his patient's compre¬ needs; hensive and continuing health care and acts as coordinator of his patient's health services. All of which may seem like a pretty tall order to a harassed practising GP who gets to see his patients for an average of 6 or 7 minutes; even so, if we are to move towards this ideal, family practice planning and statistics will have to be based on more than just expediency and guesswork. Tomorrow's patterns of practice will have to satisfy the patient, the practitioner and those who foot the bill governments. Realistic data and objectives will have to be .
.
.
found first and then acted upon in In the sixth article in the GP joining.
a
concerted way.
series, Mr. Woods discusses the
THE HOLLISTER DRAINING-WOUND
MANAGEMENT SYSTEM
KEEPS FLUIDS AWAY FROM PATIENTS SKIN AND GUARDS AGAINST IRRITATION AND CONTAMINATION. Skin-conforming Karaya Blanket protects skin around wound site. It directs discharge into odor-barrier, translucent Drainage Collector which holds exudate for visual
assessment and accurate measurement. There are no messy, wet dressings to handle or change no need for painful dressing removal. Supplied sterile, for application in O.R. or patienf s room. ...
The better alternative to absorbent dressings.
B HOLLISTER Write for more information.
Hollister Ltd., 332 Consumers Rd.,
Willowdale, Ont. M2J 1P8
CMA JOURNAL/MARCH 8, 1975/VOL. 112 637
tically
.
are
full-time administrators.
In other words, there's a lot of rather arbitrary categorizing and this tends not only to cloud the current physician manpower situation in Canada but to hamper any serious efforts to project future needs. Those needs will not be met simply by taking the number of physicians assumed to be providing primary care and dividing it into total population. Sensible forecasts of health care personnel requirements will stem from some clearer answers to questions about what services will be provided in the future, who is best equipped to provide them, what curbs on MD immigration will do to medical manpower and its distribution, what causes attrition from general practice to the specialties, should pediatricians be allowed 634 CMA JOURNAL/MARCH 8, 1975/VOL. 112
to function as "general practitioners for little people". Answers to these and other questions will depend not only on having reliable data immediately at hand, but also on our arriving at some measure of agreement about
whether the health care vehicle needs as the plethora of recent reports and commissions suggests a complete and radical overhaul or just a good lube job. So far as the existing manpower statistics are concerned, there are discrepancies; nonetheless, the figures are worth looking at because they do point up the complexities of the manpower issue. They also illustrate the differences in practice in our 10 provinces, although they don't really explain them. The College of Family Physicians claims a total of 12 922 family doctors in Canada. Health manpower at Health and Welfare Canada lists 13 333 active physicians in general and family practice (noting, incidentally, that some 4305 of these are foreign graduates; this fact will have to be taken into account in planning for the future if recently proposed legislation to curb MD immigration to Canada is passed). And the Canadian Medical Directory tape shows 12 781 general practitioners. The figures quoted are for 1972, and the problem is further compounded, for here we are into 1975 with no apparent means of judging how many GPs have traded patients for paperwork and moved into administration or other nonpractice endeavours during the past 3 years. In this connection, though, the CMD tape does tell us there are 1690 physicians in Canada who are not engaged in private practice. It is hard to tell whether these are specialists or GPs. Further, we know there are almost 6000 interns and residents, but, again, the tape doesn't indicate what these MDs will actually wind up doing or where they will do it. Perhaps the crystal ball will always be a bit cloudy, and it is possible we should draw such comfort and conclusions as we reasonably can from the facts we do have. In any event, CMD does have something to say about the ratios of family practitioners to specialists in each of the prov¬ inces. Roughly speaking, Newfoundland, Prince Edward Island and Saskatchewan have about 40% more GPs than specialists; Quebec about 40% more specialists than GPs, and in the remaining provinces the ratio is about even. All sides equal In fact, Canada, in contrast with the United States, managed to retain an almost equal split between specialists and general practitioners during the years 1968 fo 1972, although what percentage of each group is actually in full-
time medical practice is questionable. In the US, the GPto-specialist ratio has almost reversed itself over the past 40 years going from 83.5%: 16.5% in 1931 to 25.6%: 74.4% in 1971, according to the American Medical Asso¬ ciation. This may be accounted for, in some measure, by the differences in US and Canadian health care. Perhaps the only truly satisfactory way to acquire ac¬ curate data is to put tabs on all medical school graduates. In this way medical educators and health planners can have some hard facts to work with. Two PhDs, Noralou P. Roos and David G. Fish, fol¬ lowed the careers of the 1128 students who entered Cana¬ dian medical schools in 1965 and were able to track the subsequent careers of 97% of this group. They found that 47% were in general or family practice, 10% had left residency training for general practice and 8% had left general practice for residency training. Roos and Fish also discovered that the output of general practitioners varies enormously among the 12 medical schools studied, ranging from 25% at McGill to 68% at Dalhousie. This information should be of particular interest to both planners and educators, but those faced with the unenviable task of projecting provincial needs will be in¬ terested in the Roos-Fish findings in the matter of aggre¬ gate net gains or losses of the general practitioners in their study: these show Saskatchewan and Manitoba with ap¬ proximately 50% losses, all other provinces with a net loss, and only British Columbia with a net gain a rather substantial 126%.
Will
more
one,
No more guessing All of which suggests that, unpalatable though it may seem, future medical manpower planning will be based less on a laissez faire, even an intuitive, basis and more on the specialty and geographic needs of whatever health care system Canada decides to adopt. And it will begin at the medical school entrant level. It is arguable of course that governments have no busi¬ ness determining who practises what brand of medicine and where; however it is also quite clear that those picking up a $7 billion annual bill for health will expect some say in the matter. As an example, Ontario's minister of health, Frank Miller, who presides over an annual health budget of $2.3 billion and who was instrumental in drafting the proposals to restrict physician immigration, has talked about this chequerboard of Canadian MD manpower and how the pieces on it might be moved. Miller has referred to what he called an "interesting suggestion" that all medical graduates be required to serve as general practitioners in remote areas of the country before embarking on specialist courses. This, he says, is an example of the many methods we may have to consider "to rationalize the situation". Dr. Andrew T. Hunter, a London, Ont. family physician who served on the Ontario Council of Health's task force on manpower, believes that this approach used in parts of Scandinavia and in South Africa results in poor care because the drafted MDs are simply "spinning their wheels" until they can go where they really want to. If statistics about GP-to-specialist ratios are misleading, so are the often-quoted figures on numbers of physicians to
population.
The World Health Organization has decreed that a ratio of one MD to about 650 people is ideal, and Canada surpassed that optimum figure in 1973 with a ratio of 1:618. But, as we have seen, there is absolutely no point in the patient's taking his ingrown toenail to a neurosurgeon
or
his
might
basket.
MDs volunteer for underserviced areas, as did this will remote control acquire new meaning?
or
sore
not
throat to
recognize
a
a
physician-turned bureaucrat.
tonsil if
one
He turned up in his In
2000 to 1 And so, the real ratio of active primary care physicians to population may be something like 1:2000, and it's that kind of workload which may be having a disastrous effect on quality of care, professional satisfaction, and could be contributing to attrition from the general practitioner's ranks. In a 1973 article in the Journal of Medical Education, "The vanishing practitioner", Dr. Edward B. Harvey, pro¬ fessor and chairman of sociology in education at the On¬ tario Institute for Studies in Education (OISE), along with his colleague Dr. A. Hunter, looked closely at this matter of attrition. The respondents to their survey listed long hours, low prestige, too broad a spectrum of problems, difficulties in keeping abreast of new knowledge and inadequate hospital privileges as the major reasons for leaving general practice and entering a specialty. Asked about their medical school training, the GPs departing the field of primary care seemed to feel that they should have had more instruction in dealing with common ailments and other typical general practice situations; some felt they should have been exposed to greater numbers of GP teachers, while others expressed the view that a family doctor needs a more extensive training in psychiatry and in "how to manage human relationships with patients". In looking at these dropout rates the question, it seems to me, is not "Whither the GP?" but "Wither the GP?" Dr. Harvey questions: "If patterns of attrition from gen¬ eral practice are not reversed, and there seems little likelihood they will be, what means exist for alleviating resulting problems in effective health care delivery?" The point raised time and again in the discussion of who does what in medicine, and, to a lesser extent, of where is it done is that existing measurements are pretty crude. CMA JOURNAL/MARCH 8, 1975/VOL. 112 635
If the people who go into general practice find they are unsuited to it and gravitate to a specialty, this is surely a situation that could have been headed off by earlier, fuller knowledge of the aspirant GP and by proper career coun¬ selling. On the other hand, those who leave general practice because of the state of general practice itself (rather than their own condition) and who are concerned about hospital and educational facilities or inadequacies in their own training are the people for whom the College of Family Physicians should be doing its damnedest. If I have dwelt on this question of manpower it is be¬ cause, next to the changes in disease itself, the present and future numbers and distribution of family doctors will have the biggest impact on future primary care practice. Political forces
However, in any discussion of family practice one cannot
ignore the political forces presumably continue to do wonder why, if it is indeed
that
so.
and will shape it Many practitioners must .
true that Canada has one of health care systems in the if not the best the best world, there have been so many recent reports urging extensive changes to that system. While a torrent of suggestions pours forth from Lalonde, Mustard, Pickering, Hastings, Foulkes et al about what should be done to change and improve the system, the practising physician is made to look exaggeratedly con¬ servative and resistant to innovation because he's not quite sure which hoop to jump through; so, often, he decides not to jump at all. To use another analogy, the medical profession has heard the words 'on your marks' and 'get set'; but it has not yet heard the starter's gun. As an example of what I mean, there has already been some consensus among both health planners and practising physicians that the concept of the nurse practitioner is a worthy one. The newly qualified family doctor entering practice might well ask himself: "Where is the team? the nurse Where are all these allied health professionals practitioner especially that I've been expecting to work with?" At present, only McMaster University and the University of Alberta are producing nurse practitioners, and as yet there appears to be no formal mechanism for paying for even though use of the NP represents their services an economy in overall medicare costs. Dr. Donald Rice has expressed real concern about this agreement on the need for change not being followed up by change itself. "Family physicians", he says, ". find themselves in a position of wanting to practise the kind of medicine that the public seems to need and want, and find their hands are tied because the practice community is not yet ready to support this kind of practice. In their frustra¬ tion, a growing number are settling into that familiar pattern of volume practice, an adequate income, less and less professional satisfaction, ultimate disenchantment with family practice, and are finally vacating the discipline for other professional endeavours." Much the same confusion prevails in the matter of whether and how the GP should be involved in health maintenance and preventive medicine. Federal Minister of Health and Welfare Marc Lalonde, in his "New Perspective on the Health of Canadians" strongly urges: Patient, heal thyself. The question is, how? The family doctor with a couple of thousand patients on his books may have some enthusiasm for preventive .
.
.
636 CMA JOURNAL/MARCH 8, 1975/VOL. 112
..
medicine, but he simply may not have the time to do it properly; moreover, the missionary work in this field can be pretty frustrating. As Dr. James Wood, a Saskatoon family doctor with a particular interest in this subject, told me: "We've all been somewhat discouraged in our ability to persuade patients to stop smoking or to lose weight." Nonetheless, Wood believes that the GP has a part to play in identifying risk factors for, say, coronary artery disease; in taking advantage of the undoubted opportunity, though, he must have the cooperation of the patient. Proper preventive medicine, Dr. Wood contends, must be preceded by education of the public so that patients understand the need for a positive approach to health; so they work in partnership with their doctor, seeing him not just for individual episodes of disease but also occasionally when they're well. Whatever the rewards and frustrations of general prac¬ tice, there seems little doubt that governments and public alike want the family doctor. As the Ontario Council of Health noted in its 1974 report on physician manpower: "The primary or first contact physician should be the general practitioner. The specialist's services are more ef¬ fective medically, and more economic, when he concentrates on his specialized skills. Hospital facilities should continue to be available to general practitioners for the care and treatment of their patients." The council urged that the College of Family Practice (sic) and the various specialist societies determine appro¬ priate workloads for GPs and specialists in order that some estimates of future manpower needs can be arrived at. Certainly, as Dr. Donald Rice has put it, the time is now and the hour is late and the troops are getting restless so far as shaping the future of general practice is con¬ cerned. Going further, the Millis commission ("Graduate Education for General Practice" 1967) called for "a revolu¬ tion, not a few patchwork adaptations" to overcome existing disadvantages in general practice. The commission saw three major reasons for a decline in general practice: diminished prestige of this branch of medicine; limited educational opportunities, and conditions of practice that are less attractive than those enjoyed by the specialists. Clearly, family medicine, if it is to develop as an im¬ portant specialty in its own right, must be more than a stop-gap measure to relieve the crisis in primary care. The family physician, as defined by the American Medi¬ cal Association, is "one who practises in the discipline of family practice and whose training and experience qualify him to practise in several fields of medicine and surgery with particular emphasis on the family unit." The AMA goes on to state that the FP also serves the public as the physician of first contact and means of entry to the health care system; evaluates his patient's total health assumes responsibility for his patient's compre¬ needs; hensive and continuing health care and acts as coordinator of his patient's health services. All of which may seem like a pretty tall order to a harassed practising GP who gets to see his patients for an average of 6 or 7 minutes; even so, if we are to move towards this ideal, family practice planning and statistics will have to be based on more than just expediency and guesswork. Tomorrow's patterns of practice will have to satisfy the patient, the practitioner and those who foot the bill governments. Realistic data and objectives will have to be .
.
.
found first and then acted upon in In the sixth article in the GP joining.
a
concerted way.
series, Mr. Woods discusses the
THE HOLLISTER DRAINING-WOUND
MANAGEMENT SYSTEM
KEEPS FLUIDS AWAY FROM PATIENTS SKIN AND GUARDS AGAINST IRRITATION AND CONTAMINATION. Skin-conforming Karaya Blanket protects skin around wound site. It directs discharge into odor-barrier, translucent Drainage Collector which holds exudate for visual
assessment and accurate measurement. There are no messy, wet dressings to handle or change no need for painful dressing removal. Supplied sterile, for application in O.R. or patienf s room. ...
The better alternative to absorbent dressings.
B HOLLISTER Write for more information.
Hollister Ltd., 332 Consumers Rd.,
Willowdale, Ont. M2J 1P8
CMA JOURNAL/MARCH 8, 1975/VOL. 112 637
