The family doctor in Canada. Part VI: joining the organized voice By David Woods The College of Family Physicians of Canada, as it enters its 21st year, can point to an enviable record of accomplishments along the road to the maturity symbolized by its new Toronto headquarters. It is perhaps because of these achievements among them the setting up of postgraduate and undergraduate training programs in family medicine, the development of continuing education programs, formulation and adminis¬ tration of the certification exams and the provision of a variety of membership services that the college seems a little older than it really is. This impression is reinforced by the realization that, even as a tender 21-year-old, the organization is the third oldest of its type in the world, preceded in seniority only by its United States counterpart (founded in 1947) and by the Royal College of General Practitioners in Britain (1952). Also somewhat remarkable is that the college has been able to give new meaning and status to general practice in this country with a lamentably narrow membership base and with limited financial resources. Wheri it was founded in 1954 the college had 400 char¬ ter members and a donation of $10 000 from the CMA; a figure that represents today, it has 3500 members some 28% of Canada's 12 to 13 000 family physicians and is dealing with a budget that, at Dec. 31, 1973, amounted to some $300 000. The college's first president, Dr. Murray Stalker of Ormstown, Que. said on its inauguration day, June 17, 1954: "the formation of this college... marks the fulfilment of an unsatisfied need in our profession. It is our hope that this new College of General Practice will help and stimulate the family doctor to retain his position in this changing world, to the advantage of both the profes¬ sion and the public. Our efforts will not be political. It will be our main function to develop efficient family doctors, to accredit them and to maintain standards... Our broad objective is educational. This educational life is undergraduate, immediate postgraduate and through the life of the practitioner." The College Bulletin, which became, in 1961, the College of General Practice Journal, and, in 1967, Canadian Family Physician, echoed Murray Stalker's views of what the college ought to be and do. "The college is a collective effort by general practitioners to aid themselves in operat¬ ing good general practices It is not a medical-political organization. It is not simply a protest movement. It is planned to be a sort of academic headquarters with em¬ phasis on training and education. It is a serious attempt to do some of those things for the shock troops of the .
.
.
.
.
.
.
..
768 CMA JOURNAL/MARCH 22, 1975/VOL. 112
'Mr. General Practice of Canada'
profession
that the
Royal College
geons has done for the
specialist."
of
Physicians
and Sur¬
Those were the words of Dr. W. Victor Johnston, the college's first executive director. Johnston, an engaging and widely read man, was the driving force in the college's early days. A former prac¬ titioner in a small Ontario town, he wrote, in his retirement, a charming book of memoirs about country practice in the 1920s and 30s called "Before The Age of Miracles". Role of
all-purpose physicians confusing Reviewing the early objectives of the college in the 15th anniversary issue of Canadian Family Physician (Septem¬ ber 1969), Dr. Johnston commented that GPs had been confused about their role as all-purpose physicians, that
bring more science to the art of general and that they wanted a clearer definition of their role. "The college", he wrote, "has been surprisingly suc¬ it has pioneered in the task of analysing what cessful good general practice is and how to teach it.. In fact, the college has so increased the dimensions of good general practice that competence in it is now considered a specialty in its own right." The citation for honorary membership in the college bestowed on Victor Johnston in 1967 refers to him, with considerable justification, as Mr. General Practice of Canada. Before moving further into a discussion of the College of Family Physicians of Canada I think it only fair to declare my partial subjectivity. In January 1969 I became editor of the college's journal, Canadian Family Physician, and was allowed a completely free editorial hand to run the publication. Leaving the editorial chair in January 1973 I recalled, in an editor's letter in CFP, that "these have been years of very gratifying growth for this publication in terms of content, readership and advertising support; I should like to thank all of those who, in one way or another, have made my tenure here so enjoyable... I shall take with me a lasting conviction in the importance of the family physician's role in any health care system." Two years later, that conviction remains as strong as before; Canadian Family Physician, under my successor and onetime protegee, remains much as I left it. And what of the college itself? During my term of office it was an organization that reflected the inferiority to the GP rightly or wrongly complex attributed himself. It appeared to have accomplished so much and yet to have respected and promoted itself so little. Certainly, there has been something to shout about: family medicine is no longer the Cinderella it once was, and the college can credit itself with some pretty impressive alchemy in turning the pumpkin of family practice, if not into a glittering coach, at least into a rather more streamlined vehicle than it was in the 1950s. And yet the college seems today, as it did during my years there, to be an organization in search of a real reason for being, a positive identity. they
wanted to
practice .
.
.
.
Ambirion crisis This has led, in my view to what might be called a crisis of ambition; it is incredible that the organization has been able to move forward at all: the accelerator and the brakes are being applied at the same time. On the one hand, there are grandiose plans to raise $2 million for future development; on the other, there has been a parsimonious, almost hairshirted existence in which the college has struggled along with lean budgets and a skeleton staff. Today, that staff consists of an executive director, an administrative assistant, a senior secretary, a three-member journal staff one of whom doubles as a director of communications, and a covey of assorted clerical and secretarial workers numbering no more than half a dozen. Hardly adequate, one would think, to manage the affairs of a national organization; and indeed it could be said again that, in recent history, never have so many owed so much to so few. Indeed, one cannot emphasize enough: despite the thinness both of purse and personnel in the college, family medicine in Canada ranks with its counterparts in any other part of the world, and there is strong evidence to suggest, in fact, that this country has played a leadership role in bringing about a renaissance in family medicine. While the college has not been able to shake loose the
Rice:
an
abundance of presence
pursestrings of governments and industry and has somehow failed to capture the enthusiasm and support of Canada's 12 000-odd family doctors, it has been the leader of a quiet revolution during the past decade. Much of the credit for this must go to the organization's executive director, Dr. Donald Ingram Rice, a Nova Scotia family doctor who succeeded Victor Johnston in 1964. Rice is a hardworking, dedicated leader and eloquent spokesman for Canadian general practitioners. An indefatigable, inveterate traveller and ambassador, he became president of the World Organization of National Colleges and Academies and Colleges of General Practitioners/ Family Physicians an organization he helped to found last year when it met in Mexico City. As he enters his second decade of service to the college, Don Rice can point with pride to the singular accomplishments of the organization during that term of office: the fact that all but one of Canada's 16 medical schools now have departments or divisions of family medicine; the certification exams that have now been taken by over 1000 family doctors; the 1966 pilot programs in family medicine; the steady increase in membership and range of services in the college; the new headquarters. An impeccably tailored man in his 50s, Rice has an abundance of what is fashionably referred to as "presence". Whether he is addressing the twice-a-year meetings of the college's board, one of the organization's many committees or a chapter meeting in a small prairie town, he does so articulately, drawing on an encyclopedic array of up-tothe-minute facts and figures. While he has an awesome capacity to think quickly on his feet, Dr. Rice is very much in the driver's seat at the college. He portrays a somewhat patrician figure, and his strength of purpose and commitment have made him the singlemost influential force in Canadian family medicine during the past several years. Although he himself is too much a pragmatist to be labelled an intellectual, it is a tribute to his political and persuasive skills that he should have been able to lead so successfully an organization that describes itself as "academic", a "body of scholars"; it is .
continued
on
page 783
CMA JOURNAL/MARCH 22, 1975/VOL. 112 769
FAMILY DOCTOR PART VI continued from page 769 testimony to Dohald Rice's unique combination of talents
that he has been able to close the gap between academic
practising family doctors the so-called town-gown However, as Dr. Ian McWhinney, professor of family medicine at the University of Western Ontario, wrote in the February 1972 issue of Canadian Family Physician: "The relationship between universities and the practical world is too complex a thing to be expressed in a few generalities or catchwords". I think, without conspicuous paranoia, I can say that the generalities McWhinney referred to were almost cer¬ tainly my own taken from an editorial in which I had said that the nouveau riche status of academic family med¬ icine might serve to divorce it from the workaday world of family practice. But Dr. McWhinney's major point in that article ("In¬ tellectual mediocrity: the greatest threat to Canadian family medicine") was: the danger "is not that we are too aca¬ demic, but that we are not academic enough. "Our poor standard of research and scholarship," he went on, "may be excused for a few years in a developing subject. It will not be excused much longer." Research: 'do it yourselves' To be taken seriously as a branch of knowledge, went McWhinney's thesis, family medicine will very soon have and
split.
to
get down to the serious and laborious business of scholar¬
ship
sooner or later our annual conventions will have addressed not by specialists from other subjects telling us what we ought to be doing but by family physicians telling us what they are doing, backing it up with good data and careful analysis." And this, it seems to me, is the crux of the college's ambition and identity problems. On innumerable occasions I have heard mediocre papers presented at college meetings described as scholarly and erudite (often pronounced erry-yew-dite). And it is in this area of intellectual honesty and critical discernment that the college needs desperately to mature. Heaven knows the groundwork has been laid. The or¬ ganization was set up as an academic body "our broad objective", as Murray Stalker put it, "is educational". The very word college means an association of scholars; the college's motto, nostrum in studiis robur, says it all: our strength lies in study. That strength has yet to be truly shown. At present, the amount of original research, the number of original papers being produced by GPs in Canada, is small; the national library of family medicine, a commendable initia¬ tive on the part of the college, is in no danger of overuse. And the college membership requirement of 100 hours'
"...
to be
postgraduate study in each 2-year period is
a mere
drop
in the ocean of available medical knowledge. This lack of a real academic currency in the college cannot be solved by handing out newly-minted fellowships, even though some of these have undoubtedly gone to family physicians of true learning. Perhaps the solution to this problem will not be found until the college is able to draw on a much broader membership base to generate its strength first from unity and then from study. This, of course, leads us straight into the topic, much discussed in recent months, of whether the college should concern itself exclusively with academic matters anyway. Already an inflammatory subject it is also, if you will forgive the expression, an academic issue. After all, the college's present insurance and financial services hardly
qualify as educational, and in the future it will be in¬ creasingly difficult to separate political and economic mat¬ ters from educational ones. How many family physicians we will need in the 1980s and 90s, where they will practise, with whom they'll prac¬ tise, how allied health workers will be paid are all matters for the educators, but they also embrace economics and politics. To compound the problem, our present structure of health care is essentially one of provincial jurisdiction. Licensing, fee negotiations, incentives to practise in remote areas, manpower, methods of health care delivery, medi¬ care payments all of these and other matters fail within the ambit of our provincial health departments and ministries. .
Support
weak While the Canadian Medical Association has developed strong provincial satellites, the College of Family Physicians has remained a predominantly centralist organization. Apart from its Ontario chapter which accounts for half the national membership, maintains its own executive secre¬ tary in permanent offices cheek by jowl with those of the national body and runs a highly successful and well at¬ tended annual convention, the chapter organizations are weak. It is quite possible that the college's federalist stance has, paradoxically, led to a lack of coalescence. The large po¬ tential grass roots membership appears to have shrugged its collective shoulders, yawned and asked: "What can this outfit do for me?" Certainly, it would be naive to attribute the college's small paid-up membership to the educational attainments needed to join, which are quite minimal; nor could one realistically point to the annual membership fee as a deterrent, even though this was raised by $50 at the last annual assembly to $100, still quite reasonable. One must therefore ascribe the lack of solid support either to apathy or to lack of information. Of course it might be due to a genuine conviction on the part of the uncommitted GP that the college has little to offer him. In the first two cases, and possibly in the third, the college could profit by a professional and concerted ap¬ proach to public relations aimed both at members and, especially, at nonmembers. It is incredible that, 8 years after the organization changed its name to the present one, many members, even some of the luminaries, still refer to it as the College of General Practice a small point, perhaps, but a telling one. Unquestionably, great strides have been taken very recently in upgrading college PR activities: facilities for procuring speakers' papers for the press as well as those for equipment and interviews were well nigh perfect at last year's annual assembly in Winnipeg; the new publication for members, CFPC Update, will surely keep the member¬ ship further informed about college activity. Last year, the journal's business manager, George Ackehurst, acquired a new hat (which he will wear at the same time as the other one) as director of communications. Perhaps the new college headquarters will provide precisely the spur the organization needs to move ahead. Who knows, with new premises, an expanded staff, more money, the College of Family Physicians of Canada may be able to do for its own status what it has done so admirably for that of Canada's family doctors. .
.
FMOQ It's difficult to tell how many members Canada's other des medecins
general practice organization, the Federation
CMA JOURNAL/MARCH 22, 1975/VOL. 112 783
Quebec chapter, Hamel became involved in the federation's formation because of a conviction that education repre¬ sented only one facet of the GP's needs for representation. At present, he says, the FMOQ's activities range beyond purely financial matters because, in Hamel's words, every¬ thing the GP does is going to have to be negotiated conditions of practice, manpower and so on.
.
Conciliation with society Noting that the FMOQ was the only medical organiza¬ tion to favour publicly the introduction of medicare, Hamel states that GPs must "conciliate their own interests with those of society". Like the college, the FMOQ is currently engaged in manpower studies projecting Quebec's needs 5 years hence when there will be an estimated 2000 more GPs in
that province. Unlike the college, the FMOQ is heavily oriented towards public relations; in fact, despite the undeniable charm and conviction of the federation's spokesmen, the unwary visitor might be forgiven for feeling that he has wandered into a sort of postgraduate course in Dale Carnegie. Eyes gleam. Handshakes are firm. Pride is evident. Positivism abounds. "We are serene"; "We've done our homework"; "We've won all our battles". These and other expressions of con¬ fidence some might say overconfidence fill the rarefied air of the FMOQ penthouse. And indeed, there's much to be proud of: the federation concept encourages grass roots knowledge of the province and its regions; a single fee tariff for GPs and specialists is a fait accompli in Quebec; dialogue with the provincial government is, as they say, ongoing; work has been done in improving access to health care and geographic access; the organization provides a wide range of expertise and services in such areas as insurance, administration, legal advice, videocassettes, two publications, medical forms and a refresher course credit registry. Gerard Hamel attributes the fact that Quebec has a far higher percentage of specialists than GPs 40% more to immigration: because it is necessary to speak fluent French to practise in Quebec, immigrants, who are pre¬ dominantly English-speaking, tend to settle in the other .
Hamel:
success
in
Quebec helps all GPs
omnipraticiens du Quebec, has, since fees fly straight out of the Quebec GP's pocket and into the FMOQ's coffers. These members have 5% of their cheques from the health board, up to a maximum $225 a year, deducted under a checkoff system, although FMOQ president Dr. Gerard Hamel estimates that fully 2500 GPs in the province have also paid their statutory $5 joining-up fee to become active members in the federation. This kind of revenue, about a million dollars a year, can produce some pretty conspicuous consumption. And there's nothing down-at-heei about the FMOQ. Operating from plush penthouse offices in downtown Montreal, the federation employs one part-time and three full-time MDs; two full-time lawyers; two part-time legal advisers; one accountant; two lay assistant general man¬ agers; three full-time technical advisers; two librarians; one firm of actuaries, and 14 secretarial and clerical staff. And, says Gerard Hamel, "We're expanding." Not comparable Comparisons are, as we know, odious, and comparing the College of Family Physicians with the FMOQ would be particularly so because they are utterly different creatures. One is a national organization, the other provincial; one is primarily an educational body, the other mainly financial; one a voluntary club, the other, in a sense, compulsory. One is a slightly tweedy schoolteacher, the other a slick stockbroker, and as might be expected, the two have little in the way of common interests. But, however little choice may be involved in the Quebec GP's association with FMOQ, the fact remains that the college is virtually moribund in that province; it may even be that the federation is a kind of bastard child of the college.
Not that relations between the two are other than cordial, and President Gerard Hamel is an honorary member of the national body. A one time president elect of the college's
784 CMA JOURNAL/MARCH 22, 1975/VOL. 112
.
.
provinces. Asked if the FMOQ has any national aspirations, Hamel says quite definitely not; however, he allows, "When we succeed in Quebec, we help GPs throughout Canada." With the college's speaking for 28% of Canada's GPs and the federation answering for Quebec GPs only, is there a real voice of family medicine in this country? 'it is r
Certainly, the Canadian Medical Association believes there is. The way CMA Secretary General Dr. J. Douglas Wallace saw it in an article in CMAJ (Aug. 3, 1974), "To best serve all physicians in Canada fairly and equitably, the CMA has always adopted the 'undifferentiated doctor' approach. CMA membership (as well as that of the CMA board, councils and committees) is composed equally of general or family practitioners, and specialists." At present, nearly half of this country's physicians are general practitioners. The majority of them, the silent ma¬ jority, who are not members of the college, not on the councils and committees of the CMA and not living in the province of Quebec must join with those who are in one of those categories to decide whether, and how, general practice can speak with one strong voice in this country. ..
The seventh article in this series will examine the GP individual voice.
as an
.
.
.
.
.
.
..
768 CMA JOURNAL/MARCH 22, 1975/VOL. 112
'Mr. General Practice of Canada'
profession
that the
Royal College
geons has done for the
specialist."
of
Physicians
and Sur¬
Those were the words of Dr. W. Victor Johnston, the college's first executive director. Johnston, an engaging and widely read man, was the driving force in the college's early days. A former prac¬ titioner in a small Ontario town, he wrote, in his retirement, a charming book of memoirs about country practice in the 1920s and 30s called "Before The Age of Miracles". Role of
all-purpose physicians confusing Reviewing the early objectives of the college in the 15th anniversary issue of Canadian Family Physician (Septem¬ ber 1969), Dr. Johnston commented that GPs had been confused about their role as all-purpose physicians, that
bring more science to the art of general and that they wanted a clearer definition of their role. "The college", he wrote, "has been surprisingly suc¬ it has pioneered in the task of analysing what cessful good general practice is and how to teach it.. In fact, the college has so increased the dimensions of good general practice that competence in it is now considered a specialty in its own right." The citation for honorary membership in the college bestowed on Victor Johnston in 1967 refers to him, with considerable justification, as Mr. General Practice of Canada. Before moving further into a discussion of the College of Family Physicians of Canada I think it only fair to declare my partial subjectivity. In January 1969 I became editor of the college's journal, Canadian Family Physician, and was allowed a completely free editorial hand to run the publication. Leaving the editorial chair in January 1973 I recalled, in an editor's letter in CFP, that "these have been years of very gratifying growth for this publication in terms of content, readership and advertising support; I should like to thank all of those who, in one way or another, have made my tenure here so enjoyable... I shall take with me a lasting conviction in the importance of the family physician's role in any health care system." Two years later, that conviction remains as strong as before; Canadian Family Physician, under my successor and onetime protegee, remains much as I left it. And what of the college itself? During my term of office it was an organization that reflected the inferiority to the GP rightly or wrongly complex attributed himself. It appeared to have accomplished so much and yet to have respected and promoted itself so little. Certainly, there has been something to shout about: family medicine is no longer the Cinderella it once was, and the college can credit itself with some pretty impressive alchemy in turning the pumpkin of family practice, if not into a glittering coach, at least into a rather more streamlined vehicle than it was in the 1950s. And yet the college seems today, as it did during my years there, to be an organization in search of a real reason for being, a positive identity. they
wanted to
practice .
.
.
.
Ambirion crisis This has led, in my view to what might be called a crisis of ambition; it is incredible that the organization has been able to move forward at all: the accelerator and the brakes are being applied at the same time. On the one hand, there are grandiose plans to raise $2 million for future development; on the other, there has been a parsimonious, almost hairshirted existence in which the college has struggled along with lean budgets and a skeleton staff. Today, that staff consists of an executive director, an administrative assistant, a senior secretary, a three-member journal staff one of whom doubles as a director of communications, and a covey of assorted clerical and secretarial workers numbering no more than half a dozen. Hardly adequate, one would think, to manage the affairs of a national organization; and indeed it could be said again that, in recent history, never have so many owed so much to so few. Indeed, one cannot emphasize enough: despite the thinness both of purse and personnel in the college, family medicine in Canada ranks with its counterparts in any other part of the world, and there is strong evidence to suggest, in fact, that this country has played a leadership role in bringing about a renaissance in family medicine. While the college has not been able to shake loose the
Rice:
an
abundance of presence
pursestrings of governments and industry and has somehow failed to capture the enthusiasm and support of Canada's 12 000-odd family doctors, it has been the leader of a quiet revolution during the past decade. Much of the credit for this must go to the organization's executive director, Dr. Donald Ingram Rice, a Nova Scotia family doctor who succeeded Victor Johnston in 1964. Rice is a hardworking, dedicated leader and eloquent spokesman for Canadian general practitioners. An indefatigable, inveterate traveller and ambassador, he became president of the World Organization of National Colleges and Academies and Colleges of General Practitioners/ Family Physicians an organization he helped to found last year when it met in Mexico City. As he enters his second decade of service to the college, Don Rice can point with pride to the singular accomplishments of the organization during that term of office: the fact that all but one of Canada's 16 medical schools now have departments or divisions of family medicine; the certification exams that have now been taken by over 1000 family doctors; the 1966 pilot programs in family medicine; the steady increase in membership and range of services in the college; the new headquarters. An impeccably tailored man in his 50s, Rice has an abundance of what is fashionably referred to as "presence". Whether he is addressing the twice-a-year meetings of the college's board, one of the organization's many committees or a chapter meeting in a small prairie town, he does so articulately, drawing on an encyclopedic array of up-tothe-minute facts and figures. While he has an awesome capacity to think quickly on his feet, Dr. Rice is very much in the driver's seat at the college. He portrays a somewhat patrician figure, and his strength of purpose and commitment have made him the singlemost influential force in Canadian family medicine during the past several years. Although he himself is too much a pragmatist to be labelled an intellectual, it is a tribute to his political and persuasive skills that he should have been able to lead so successfully an organization that describes itself as "academic", a "body of scholars"; it is .
continued
on
page 783
CMA JOURNAL/MARCH 22, 1975/VOL. 112 769
FAMILY DOCTOR PART VI continued from page 769 testimony to Dohald Rice's unique combination of talents
that he has been able to close the gap between academic
practising family doctors the so-called town-gown However, as Dr. Ian McWhinney, professor of family medicine at the University of Western Ontario, wrote in the February 1972 issue of Canadian Family Physician: "The relationship between universities and the practical world is too complex a thing to be expressed in a few generalities or catchwords". I think, without conspicuous paranoia, I can say that the generalities McWhinney referred to were almost cer¬ tainly my own taken from an editorial in which I had said that the nouveau riche status of academic family med¬ icine might serve to divorce it from the workaday world of family practice. But Dr. McWhinney's major point in that article ("In¬ tellectual mediocrity: the greatest threat to Canadian family medicine") was: the danger "is not that we are too aca¬ demic, but that we are not academic enough. "Our poor standard of research and scholarship," he went on, "may be excused for a few years in a developing subject. It will not be excused much longer." Research: 'do it yourselves' To be taken seriously as a branch of knowledge, went McWhinney's thesis, family medicine will very soon have and
split.
to
get down to the serious and laborious business of scholar¬
ship
sooner or later our annual conventions will have addressed not by specialists from other subjects telling us what we ought to be doing but by family physicians telling us what they are doing, backing it up with good data and careful analysis." And this, it seems to me, is the crux of the college's ambition and identity problems. On innumerable occasions I have heard mediocre papers presented at college meetings described as scholarly and erudite (often pronounced erry-yew-dite). And it is in this area of intellectual honesty and critical discernment that the college needs desperately to mature. Heaven knows the groundwork has been laid. The or¬ ganization was set up as an academic body "our broad objective", as Murray Stalker put it, "is educational". The very word college means an association of scholars; the college's motto, nostrum in studiis robur, says it all: our strength lies in study. That strength has yet to be truly shown. At present, the amount of original research, the number of original papers being produced by GPs in Canada, is small; the national library of family medicine, a commendable initia¬ tive on the part of the college, is in no danger of overuse. And the college membership requirement of 100 hours'
"...
to be
postgraduate study in each 2-year period is
a mere
drop
in the ocean of available medical knowledge. This lack of a real academic currency in the college cannot be solved by handing out newly-minted fellowships, even though some of these have undoubtedly gone to family physicians of true learning. Perhaps the solution to this problem will not be found until the college is able to draw on a much broader membership base to generate its strength first from unity and then from study. This, of course, leads us straight into the topic, much discussed in recent months, of whether the college should concern itself exclusively with academic matters anyway. Already an inflammatory subject it is also, if you will forgive the expression, an academic issue. After all, the college's present insurance and financial services hardly
qualify as educational, and in the future it will be in¬ creasingly difficult to separate political and economic mat¬ ters from educational ones. How many family physicians we will need in the 1980s and 90s, where they will practise, with whom they'll prac¬ tise, how allied health workers will be paid are all matters for the educators, but they also embrace economics and politics. To compound the problem, our present structure of health care is essentially one of provincial jurisdiction. Licensing, fee negotiations, incentives to practise in remote areas, manpower, methods of health care delivery, medi¬ care payments all of these and other matters fail within the ambit of our provincial health departments and ministries. .
Support
weak While the Canadian Medical Association has developed strong provincial satellites, the College of Family Physicians has remained a predominantly centralist organization. Apart from its Ontario chapter which accounts for half the national membership, maintains its own executive secre¬ tary in permanent offices cheek by jowl with those of the national body and runs a highly successful and well at¬ tended annual convention, the chapter organizations are weak. It is quite possible that the college's federalist stance has, paradoxically, led to a lack of coalescence. The large po¬ tential grass roots membership appears to have shrugged its collective shoulders, yawned and asked: "What can this outfit do for me?" Certainly, it would be naive to attribute the college's small paid-up membership to the educational attainments needed to join, which are quite minimal; nor could one realistically point to the annual membership fee as a deterrent, even though this was raised by $50 at the last annual assembly to $100, still quite reasonable. One must therefore ascribe the lack of solid support either to apathy or to lack of information. Of course it might be due to a genuine conviction on the part of the uncommitted GP that the college has little to offer him. In the first two cases, and possibly in the third, the college could profit by a professional and concerted ap¬ proach to public relations aimed both at members and, especially, at nonmembers. It is incredible that, 8 years after the organization changed its name to the present one, many members, even some of the luminaries, still refer to it as the College of General Practice a small point, perhaps, but a telling one. Unquestionably, great strides have been taken very recently in upgrading college PR activities: facilities for procuring speakers' papers for the press as well as those for equipment and interviews were well nigh perfect at last year's annual assembly in Winnipeg; the new publication for members, CFPC Update, will surely keep the member¬ ship further informed about college activity. Last year, the journal's business manager, George Ackehurst, acquired a new hat (which he will wear at the same time as the other one) as director of communications. Perhaps the new college headquarters will provide precisely the spur the organization needs to move ahead. Who knows, with new premises, an expanded staff, more money, the College of Family Physicians of Canada may be able to do for its own status what it has done so admirably for that of Canada's family doctors. .
.
FMOQ It's difficult to tell how many members Canada's other des medecins
general practice organization, the Federation
CMA JOURNAL/MARCH 22, 1975/VOL. 112 783
Quebec chapter, Hamel became involved in the federation's formation because of a conviction that education repre¬ sented only one facet of the GP's needs for representation. At present, he says, the FMOQ's activities range beyond purely financial matters because, in Hamel's words, every¬ thing the GP does is going to have to be negotiated conditions of practice, manpower and so on.
.
Conciliation with society Noting that the FMOQ was the only medical organiza¬ tion to favour publicly the introduction of medicare, Hamel states that GPs must "conciliate their own interests with those of society". Like the college, the FMOQ is currently engaged in manpower studies projecting Quebec's needs 5 years hence when there will be an estimated 2000 more GPs in
that province. Unlike the college, the FMOQ is heavily oriented towards public relations; in fact, despite the undeniable charm and conviction of the federation's spokesmen, the unwary visitor might be forgiven for feeling that he has wandered into a sort of postgraduate course in Dale Carnegie. Eyes gleam. Handshakes are firm. Pride is evident. Positivism abounds. "We are serene"; "We've done our homework"; "We've won all our battles". These and other expressions of con¬ fidence some might say overconfidence fill the rarefied air of the FMOQ penthouse. And indeed, there's much to be proud of: the federation concept encourages grass roots knowledge of the province and its regions; a single fee tariff for GPs and specialists is a fait accompli in Quebec; dialogue with the provincial government is, as they say, ongoing; work has been done in improving access to health care and geographic access; the organization provides a wide range of expertise and services in such areas as insurance, administration, legal advice, videocassettes, two publications, medical forms and a refresher course credit registry. Gerard Hamel attributes the fact that Quebec has a far higher percentage of specialists than GPs 40% more to immigration: because it is necessary to speak fluent French to practise in Quebec, immigrants, who are pre¬ dominantly English-speaking, tend to settle in the other .
Hamel:
success
in
Quebec helps all GPs
omnipraticiens du Quebec, has, since fees fly straight out of the Quebec GP's pocket and into the FMOQ's coffers. These members have 5% of their cheques from the health board, up to a maximum $225 a year, deducted under a checkoff system, although FMOQ president Dr. Gerard Hamel estimates that fully 2500 GPs in the province have also paid their statutory $5 joining-up fee to become active members in the federation. This kind of revenue, about a million dollars a year, can produce some pretty conspicuous consumption. And there's nothing down-at-heei about the FMOQ. Operating from plush penthouse offices in downtown Montreal, the federation employs one part-time and three full-time MDs; two full-time lawyers; two part-time legal advisers; one accountant; two lay assistant general man¬ agers; three full-time technical advisers; two librarians; one firm of actuaries, and 14 secretarial and clerical staff. And, says Gerard Hamel, "We're expanding." Not comparable Comparisons are, as we know, odious, and comparing the College of Family Physicians with the FMOQ would be particularly so because they are utterly different creatures. One is a national organization, the other provincial; one is primarily an educational body, the other mainly financial; one a voluntary club, the other, in a sense, compulsory. One is a slightly tweedy schoolteacher, the other a slick stockbroker, and as might be expected, the two have little in the way of common interests. But, however little choice may be involved in the Quebec GP's association with FMOQ, the fact remains that the college is virtually moribund in that province; it may even be that the federation is a kind of bastard child of the college.
Not that relations between the two are other than cordial, and President Gerard Hamel is an honorary member of the national body. A one time president elect of the college's
784 CMA JOURNAL/MARCH 22, 1975/VOL. 112
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provinces. Asked if the FMOQ has any national aspirations, Hamel says quite definitely not; however, he allows, "When we succeed in Quebec, we help GPs throughout Canada." With the college's speaking for 28% of Canada's GPs and the federation answering for Quebec GPs only, is there a real voice of family medicine in this country? 'it is r
Certainly, the Canadian Medical Association believes there is. The way CMA Secretary General Dr. J. Douglas Wallace saw it in an article in CMAJ (Aug. 3, 1974), "To best serve all physicians in Canada fairly and equitably, the CMA has always adopted the 'undifferentiated doctor' approach. CMA membership (as well as that of the CMA board, councils and committees) is composed equally of general or family practitioners, and specialists." At present, nearly half of this country's physicians are general practitioners. The majority of them, the silent ma¬ jority, who are not members of the college, not on the councils and committees of the CMA and not living in the province of Quebec must join with those who are in one of those categories to decide whether, and how, general practice can speak with one strong voice in this country. ..
The seventh article in this series will examine the GP individual voice.
as an
