wmmmmmasm *\^'^47SX?
The family doctor in Canada. Part VII: a group of six By David Woods An age range from the 3 rd to the 7th decade, two certificants, two fellowships and two chapter presidencies in the College of Family Physicians of Canada, a former chairmanship of the Ontario Medical Association's section on general practice, a current membership in that section, group, solo and partnership practice, family medicine teach¬
ing experience, a ranking academic, a residency-trained, and a committed nonpurpose-built family doctor member of the college. All of that and, as they say in the advertisements, much, .
much more, was embodied in five GP/family doctors who discussed their views with CMAJ one snowy Saturday in February at the University of Western Ontario. We started with an innocuous enough question: Is there any difference between a general practitioner and a family physician? The ensuing lengthy discussion reflected the conflicts and uncertainties underlying this seemingly semantic issue. Dr. Andrew Hunter, assistant dean of continuing medical education at Western, sees family practice as a refinement of general practice and believes that all effective GPs are de facto family doctors. Dr. John Sangster, a young product of specific residency training in family medicine, says that the newer term has evolved along with the discipline it describes. What others learned essentially "by the seat of their pants", he observes, is now an established, defined element in the medical school curriculum. Dr. Paul Brady, a GP since 1940, sees no clear difference. Even though he is called a family physician today, he doesn't think his pattern of practice has changed much over the years. Dr. Leigh Naftolin of the OMA's section on general there's practice (not family practice, you will notice) thinks his of Members difference. a group mainly psychological have changed their shingle and their letterhead to read "family physicians". It's a clearer definition of their role, he says. In general, dated In fact, the panel seemed to agree that even if general and family practice are the same thing, the term general perhaps even to practice was beginning to be dated John take on some pejorative overtones. As Sangster put it: "Certainly in medical school circles the concept existed that general practice was that that people were just GPs thing you did if you didn't specialize that thing out there that you could always go and do. Now we realize it's got a name; it's that that thing is really something got an area of skills that are its own." Does the patient notice any difference? Well, he's certainly noticed the change, the panel felt, because the public perhaps more than the medical pro¬ has latched on to the term "family physician" fession in an almost proprietary way "my family doctor". .
...
..
.
.
908 CMA JOURNAL/APRIL 5, 1975/VOL. 112
Dr. Hunter concluded that family practice is more than a mosaic made up of the various medical disciplines; rather, it is a different clinical method of caring for people than is used by others. But academically, he says, we have made it difficult for ourselves by trying to define family medicine too rigidly. While it is an almost indefinable
just
discipline, it is not that difficult to dissect as a clinical meth¬ od, as an approach. Essentially, it is a way of doing
much of it learned from experience and follow-up rather than a strictly academic subject. In his particular area of current interest continuing Hunter feels there's a similar danger medical education of getting locked into definitions. The term itself, he says, implies that there is a teacher, presenting information, and a recipient who has to do something with that information. Hunter therefore prefers to talk about "continuing learning" "because that's where the guts of the thing lie." One of the greatest benefits of practising in a group, he says, is the continuing learning process this provides. Dr. Paul Brady believes that, to keep up to date, the practitioner must avail himself of all the options formal meetings and courses, journals, tapes, books. But he agreed with Dr. Hunter that much valuable knowledge comes from day-to-day discussion with specialist and family physi¬ cian colleagues. The main things, he says, are to have a desire to improve and update one's knowledge and to evaluate performance. This matter of self-evaluation is central to the learning process in family medicine, the group agreed. In fact, Dr. Hunter pointed out, the whole idea of medical education should inculcate in people the desire to evaluate themselves. The problem, he says, is that in medical school "you're always evaluated by someone else; the guy who finishes medical school often assumes that this will continue to be the case." But if he doesn't learn to assess his own knowl¬ edge and competence, he will face the possibility of be-
things
.
coming stagnant. The panel showed
some ambivalence about continuing medical education's being outside-directed (for example evidence of a certain amount of it could become a con¬ dition of relicensure). Its members did feel, however, that such as the mulformalized methods of self-evaluation in Canadian times a featured six year questions tiple-choice are useful for measuring individual Family Physician standards against prevailing or expected ones. This led to a discussion of the CFPC's seemingly minimal evidence of at least 100 hours condition of membership of postgraduate study in any 2-year period. Dr. Sangster felt that all this really means is getting across the idea of continuing learning, giving family doc¬ tors an incentive to devote some of their hard-come-by time to polishing up old knowledge and seeking out new. Nonetheless, he wondered whether it was really neces¬ sary to get people to "sign on the dotted line" that they had, in fact, attended such and such a course or read
so-and-so's article. Dr. Brady weighed in with an observa¬ on his more than 35 years in practice, that don't show up at the scientific meetings usually who people aren't doing very much else to keep abreast of new
tion, based
knowledge. There was general agreement among the group, as might be expected, that greater financial or tax inducements should be available for the family doctor who wants to update his education. More people would approach the CME process more wholeheartedly, with much more commitment, said Dr. Sangster, if they had some assurance that their going away for a couple of weeks or more would not create an economic disruption for them. The locum tenens and study fellowship programs are a start, the panel felt, but they need to be made much more widely accessible. One-man majority Of the five panellists, only one, Dr. Enzo Sivilotti, was not a member of the College of Family Physicians of Canada. While he may have been a minority voice at this discussion, he is, as we have already seen in this series of articles, within the 62% majority of Canada's family doctors who are not college members. His decision not to join appears to be a conscious one, and, since he did not seem to be unduly moved by the sentiments expressed by other panellists, one must assume that he remains convinced, in his words, that "the college has nothing to offer." Dr. Paul Brady, a long-time member, pointed out that "before the advent of the college, representation of the general practitioner was nil." It wasn't until the college was formed, said Brady, that the GP began to attain some status. Dr. Sangster said that he feels represented, although he at least in Ontario noted that representation of the GP is somewhat fragmented. Panel members reiterated the college's achievements, with Dr. Enzo Sivilotti standing by his judgement that "the college would not contribute to my practice in any way." But he admitted he had heard points about the organization that he had not been aware of until he had taken part which again seems to underline one of the in the panel college's basic problems, that it is not a "do-nothing" outfit, but a "tell-little" one. It has somehow been unable to match its performance with its public relations. The college may well have been not failing to do things but failing to demonstrate (particularly to the unconverted) the products. This is a matter not just of explaining specific activities but of getting across more intangible factors such as "philosophy". But as Paul Brady put it: "How do you tell the people that, before the college came on the scene, Canadian GP was in real danger of becoming as extinct as the North American bison?" Brady also expressed the view that he hoped the college would not get involved in economics "because once it does, it will be labelled as 'being in it for the money'." He sees the OMA section on general practice as being the economic arm of the (GP) profession, though "whether they're doing that's open to question; they're cer¬ a good job or not tainly not as slick as the federation (FMOQ) in Quebec." Is education apolitical? Dr. Brady encountered some opposition to his view that the college should remain a purely educational body. Dr. Sangster said that he'd like to see the college's prime
interest remain in education "but I want it to also take some interest in economics because I feel that it understands what I believe in... and I don't believe you can dissociate economics from (patterns of practice)." Dr. Leigh Naftolin, who serves on the OMA's section
ELDOmUN
BJXIRO^L BRONCHODWIOR (theophyllinelixir)
Convenient relief for patients of all ages. information available Complete prescribing orconsult C.P.S.
on
request,
Elixophyllin is listed in the following: Quebec Drug List Ontario Drug Benefit Drug Formulary Manitoba Ph arm acare Saskatchewan Prescription Drug Plan
(jooper Medical Division
Cooper Laboratories Ltd. Ste. Therese, Quebec
CMA JOURNAL/APRIL 5, 1975/VOL. 112 909
general practice, said that education will remain at the new family physi¬ cians are now looking at the college as their arm in economics as well." He pointed out that the college now has direct representation on the OMA section and has been asked to comment on the Mustard report, for example. Dr. Hunter agreed that the college is primarily an educa¬ tional body. But by virtue of its being so, he said, it is also concerned about quality of care. This means that there cannot be "production line" medicine; you have to do it slowly and carefully "and when you're paid on a unit basis, as we are, you incur penalties." Practitioners, said Hunter, are not satisfied with volume practice; somebody has to sort out the payment mechanism and the discrepancy between GPs' incomes and those of some specialists. He expressed some ambivalence about whether the college should do this, but noted that, if someone doesn't do it, family physicians will be justified in taking a more militant position to ensure that they are not penalized economically by practising a higher standard of medicine. In effect, the college appears to be into economics whether it likes it or not. As Leigh Naftolin said: "The college has painted a baseline of how good medicine should be practised... if we attempt to follow it up we lose money." While there appeared to be no uniformity of opinion among the panel about how GPs should be paid, there was agreement that family doctors aren't paid enough for what they do and that the method of payment needs to be more fluid in taking into account the time-consuming coun¬ selling that is an integral part of good general practice. As someone observed, it's no accident that psychiatrists, who have limited opportunity for anything resembling assemblyline methods, are the lowest paid of the medical specialties. There followed some discussion about drawing together on
top of the college's priorities "but the ...
.
Basic Prenatal
Supplement
Each Prenavite film-coated tablet supplies: 150mg ferrous fumarate, 4,000 I.U.Vit.A acetate, 400 I.U.Vit. D2,100 mg ascorbic acid [as ascorbate), 2.5 mg folic acid, 125mg calcium carbonate. Prenavite Forte has 50% more iron. Film-coated. easy to swallow.
Prenavite Prenavite Forte Full information available on request.
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the ideals of practice with the realities: for example, most family doctors favour the idea of employing the services of nurse practitioners. But where are those nurse practi¬ tioners? And how do you pay them if you're lucky enough to find them? Asked about how they see future developments within their specialized area of medicine, the panellists came back to the subject of maintaining a quality of practice that would be both fulfilling to them and beneficial to their patients; they wanted to maintain hospital access in order to provide continuing care within the community; they wanted to retain professional autonomy and dignity.
Hopes dwindling Dr. Hunter said that he wasn't quite as optimistic about the future of general practice as he once was, and he was concerned about its economic aspects. He said he would like to see government or some other clinics. agency set up facilities for general practice The only problem with that, said Dr. Brady, is that once you get public assistance you begin to get domination by the payers. Brady also referred to Ontario Health Minister Frank Miller's recently expressed desire to eliminate hos¬ pitals with fewer than 100 beds. "If that came about," he said, "the GP in the rural areas would become a dodo." Concerned about regimentation of the future family physician, Brady said that he'd told his son who has just graduated in medicine: if GPs are going to be told where they may or may not practise, then forget about general practice. Agreeing that Canada's health care system is in generally pretty good shape, the panel tended toward concern even alarm that proliferating reports urge wholesale change. However, they admitted that improvements in availability and accessibility of care could be made, and that the system, in Dr. Hunter's words, "probably could do with a bit of moulding and adjusting. But I think it should be done on the base of what we have now." Dr. Brady's response to a question about the future GP's role in preventive medicine was interesting: "What do they think we've been practising?" he asked. And there was much enthusiasm around the table for this observation. Even so, the presence of so much and increasing amounts of "self-induced disease", such as accidents and cardiovascular and obesity problems suggests that prev¬ entive counselling work is losing its battle. Indeed the family doctors gathered for this panel dis¬ cussion report it to be a frustrating element of their prac¬ tice. Merely supplying information doesn't really seem to work, but anything more active begins to infringe on the patient's rights. You can't legislate lifestyle. Dr. Sangster made the point, too, that not only should public education by the family doctor be nonjudging, it also should teach about how to use the health care system "because people who know how to use the system today really don't have too much trouble in getting top quality care." The discussion ended with some commentary on the public image of doctors, and, while there was nothing even remotely approaching paranoia on the subject, the panellists agreed that the medical profession had not in general come across too well to the man-in-the-street particularly where economic issues are concerned. The team finally dispersed, and, interestingly enough, most of those who had given up part of their weekend to join it appeared to be headed toward at least some further professional obligation that Saturday afternoon. .
.
.
.
.
.
David Woods' final article in this series, in the next issue of CMAJ, examines the way ahead for the family doctor in
Canada.
910 CMA JOURNAL/APRIL 5, 1975/VOL. 112
The family doctor in Canada. Part VII: a group of six By David Woods An age range from the 3 rd to the 7th decade, two certificants, two fellowships and two chapter presidencies in the College of Family Physicians of Canada, a former chairmanship of the Ontario Medical Association's section on general practice, a current membership in that section, group, solo and partnership practice, family medicine teach¬
ing experience, a ranking academic, a residency-trained, and a committed nonpurpose-built family doctor member of the college. All of that and, as they say in the advertisements, much, .
much more, was embodied in five GP/family doctors who discussed their views with CMAJ one snowy Saturday in February at the University of Western Ontario. We started with an innocuous enough question: Is there any difference between a general practitioner and a family physician? The ensuing lengthy discussion reflected the conflicts and uncertainties underlying this seemingly semantic issue. Dr. Andrew Hunter, assistant dean of continuing medical education at Western, sees family practice as a refinement of general practice and believes that all effective GPs are de facto family doctors. Dr. John Sangster, a young product of specific residency training in family medicine, says that the newer term has evolved along with the discipline it describes. What others learned essentially "by the seat of their pants", he observes, is now an established, defined element in the medical school curriculum. Dr. Paul Brady, a GP since 1940, sees no clear difference. Even though he is called a family physician today, he doesn't think his pattern of practice has changed much over the years. Dr. Leigh Naftolin of the OMA's section on general there's practice (not family practice, you will notice) thinks his of Members difference. a group mainly psychological have changed their shingle and their letterhead to read "family physicians". It's a clearer definition of their role, he says. In general, dated In fact, the panel seemed to agree that even if general and family practice are the same thing, the term general perhaps even to practice was beginning to be dated John take on some pejorative overtones. As Sangster put it: "Certainly in medical school circles the concept existed that general practice was that that people were just GPs thing you did if you didn't specialize that thing out there that you could always go and do. Now we realize it's got a name; it's that that thing is really something got an area of skills that are its own." Does the patient notice any difference? Well, he's certainly noticed the change, the panel felt, because the public perhaps more than the medical pro¬ has latched on to the term "family physician" fession in an almost proprietary way "my family doctor". .
...
..
.
.
908 CMA JOURNAL/APRIL 5, 1975/VOL. 112
Dr. Hunter concluded that family practice is more than a mosaic made up of the various medical disciplines; rather, it is a different clinical method of caring for people than is used by others. But academically, he says, we have made it difficult for ourselves by trying to define family medicine too rigidly. While it is an almost indefinable
just
discipline, it is not that difficult to dissect as a clinical meth¬ od, as an approach. Essentially, it is a way of doing
much of it learned from experience and follow-up rather than a strictly academic subject. In his particular area of current interest continuing Hunter feels there's a similar danger medical education of getting locked into definitions. The term itself, he says, implies that there is a teacher, presenting information, and a recipient who has to do something with that information. Hunter therefore prefers to talk about "continuing learning" "because that's where the guts of the thing lie." One of the greatest benefits of practising in a group, he says, is the continuing learning process this provides. Dr. Paul Brady believes that, to keep up to date, the practitioner must avail himself of all the options formal meetings and courses, journals, tapes, books. But he agreed with Dr. Hunter that much valuable knowledge comes from day-to-day discussion with specialist and family physi¬ cian colleagues. The main things, he says, are to have a desire to improve and update one's knowledge and to evaluate performance. This matter of self-evaluation is central to the learning process in family medicine, the group agreed. In fact, Dr. Hunter pointed out, the whole idea of medical education should inculcate in people the desire to evaluate themselves. The problem, he says, is that in medical school "you're always evaluated by someone else; the guy who finishes medical school often assumes that this will continue to be the case." But if he doesn't learn to assess his own knowl¬ edge and competence, he will face the possibility of be-
things
.
coming stagnant. The panel showed
some ambivalence about continuing medical education's being outside-directed (for example evidence of a certain amount of it could become a con¬ dition of relicensure). Its members did feel, however, that such as the mulformalized methods of self-evaluation in Canadian times a featured six year questions tiple-choice are useful for measuring individual Family Physician standards against prevailing or expected ones. This led to a discussion of the CFPC's seemingly minimal evidence of at least 100 hours condition of membership of postgraduate study in any 2-year period. Dr. Sangster felt that all this really means is getting across the idea of continuing learning, giving family doc¬ tors an incentive to devote some of their hard-come-by time to polishing up old knowledge and seeking out new. Nonetheless, he wondered whether it was really neces¬ sary to get people to "sign on the dotted line" that they had, in fact, attended such and such a course or read
so-and-so's article. Dr. Brady weighed in with an observa¬ on his more than 35 years in practice, that don't show up at the scientific meetings usually who people aren't doing very much else to keep abreast of new
tion, based
knowledge. There was general agreement among the group, as might be expected, that greater financial or tax inducements should be available for the family doctor who wants to update his education. More people would approach the CME process more wholeheartedly, with much more commitment, said Dr. Sangster, if they had some assurance that their going away for a couple of weeks or more would not create an economic disruption for them. The locum tenens and study fellowship programs are a start, the panel felt, but they need to be made much more widely accessible. One-man majority Of the five panellists, only one, Dr. Enzo Sivilotti, was not a member of the College of Family Physicians of Canada. While he may have been a minority voice at this discussion, he is, as we have already seen in this series of articles, within the 62% majority of Canada's family doctors who are not college members. His decision not to join appears to be a conscious one, and, since he did not seem to be unduly moved by the sentiments expressed by other panellists, one must assume that he remains convinced, in his words, that "the college has nothing to offer." Dr. Paul Brady, a long-time member, pointed out that "before the advent of the college, representation of the general practitioner was nil." It wasn't until the college was formed, said Brady, that the GP began to attain some status. Dr. Sangster said that he feels represented, although he at least in Ontario noted that representation of the GP is somewhat fragmented. Panel members reiterated the college's achievements, with Dr. Enzo Sivilotti standing by his judgement that "the college would not contribute to my practice in any way." But he admitted he had heard points about the organization that he had not been aware of until he had taken part which again seems to underline one of the in the panel college's basic problems, that it is not a "do-nothing" outfit, but a "tell-little" one. It has somehow been unable to match its performance with its public relations. The college may well have been not failing to do things but failing to demonstrate (particularly to the unconverted) the products. This is a matter not just of explaining specific activities but of getting across more intangible factors such as "philosophy". But as Paul Brady put it: "How do you tell the people that, before the college came on the scene, Canadian GP was in real danger of becoming as extinct as the North American bison?" Brady also expressed the view that he hoped the college would not get involved in economics "because once it does, it will be labelled as 'being in it for the money'." He sees the OMA section on general practice as being the economic arm of the (GP) profession, though "whether they're doing that's open to question; they're cer¬ a good job or not tainly not as slick as the federation (FMOQ) in Quebec." Is education apolitical? Dr. Brady encountered some opposition to his view that the college should remain a purely educational body. Dr. Sangster said that he'd like to see the college's prime
interest remain in education "but I want it to also take some interest in economics because I feel that it understands what I believe in... and I don't believe you can dissociate economics from (patterns of practice)." Dr. Leigh Naftolin, who serves on the OMA's section
ELDOmUN
BJXIRO^L BRONCHODWIOR (theophyllinelixir)
Convenient relief for patients of all ages. information available Complete prescribing orconsult C.P.S.
on
request,
Elixophyllin is listed in the following: Quebec Drug List Ontario Drug Benefit Drug Formulary Manitoba Ph arm acare Saskatchewan Prescription Drug Plan
(jooper Medical Division
Cooper Laboratories Ltd. Ste. Therese, Quebec
CMA JOURNAL/APRIL 5, 1975/VOL. 112 909
general practice, said that education will remain at the new family physi¬ cians are now looking at the college as their arm in economics as well." He pointed out that the college now has direct representation on the OMA section and has been asked to comment on the Mustard report, for example. Dr. Hunter agreed that the college is primarily an educa¬ tional body. But by virtue of its being so, he said, it is also concerned about quality of care. This means that there cannot be "production line" medicine; you have to do it slowly and carefully "and when you're paid on a unit basis, as we are, you incur penalties." Practitioners, said Hunter, are not satisfied with volume practice; somebody has to sort out the payment mechanism and the discrepancy between GPs' incomes and those of some specialists. He expressed some ambivalence about whether the college should do this, but noted that, if someone doesn't do it, family physicians will be justified in taking a more militant position to ensure that they are not penalized economically by practising a higher standard of medicine. In effect, the college appears to be into economics whether it likes it or not. As Leigh Naftolin said: "The college has painted a baseline of how good medicine should be practised... if we attempt to follow it up we lose money." While there appeared to be no uniformity of opinion among the panel about how GPs should be paid, there was agreement that family doctors aren't paid enough for what they do and that the method of payment needs to be more fluid in taking into account the time-consuming coun¬ selling that is an integral part of good general practice. As someone observed, it's no accident that psychiatrists, who have limited opportunity for anything resembling assemblyline methods, are the lowest paid of the medical specialties. There followed some discussion about drawing together on
top of the college's priorities "but the ...
.
Basic Prenatal
Supplement
Each Prenavite film-coated tablet supplies: 150mg ferrous fumarate, 4,000 I.U.Vit.A acetate, 400 I.U.Vit. D2,100 mg ascorbic acid [as ascorbate), 2.5 mg folic acid, 125mg calcium carbonate. Prenavite Forte has 50% more iron. Film-coated. easy to swallow.
Prenavite Prenavite Forte Full information available on request.
A\ Allen & Hanburys (FormerlyBDH
Pharmaceuticals) Toronto, Montreal
the ideals of practice with the realities: for example, most family doctors favour the idea of employing the services of nurse practitioners. But where are those nurse practi¬ tioners? And how do you pay them if you're lucky enough to find them? Asked about how they see future developments within their specialized area of medicine, the panellists came back to the subject of maintaining a quality of practice that would be both fulfilling to them and beneficial to their patients; they wanted to maintain hospital access in order to provide continuing care within the community; they wanted to retain professional autonomy and dignity.
Hopes dwindling Dr. Hunter said that he wasn't quite as optimistic about the future of general practice as he once was, and he was concerned about its economic aspects. He said he would like to see government or some other clinics. agency set up facilities for general practice The only problem with that, said Dr. Brady, is that once you get public assistance you begin to get domination by the payers. Brady also referred to Ontario Health Minister Frank Miller's recently expressed desire to eliminate hos¬ pitals with fewer than 100 beds. "If that came about," he said, "the GP in the rural areas would become a dodo." Concerned about regimentation of the future family physician, Brady said that he'd told his son who has just graduated in medicine: if GPs are going to be told where they may or may not practise, then forget about general practice. Agreeing that Canada's health care system is in generally pretty good shape, the panel tended toward concern even alarm that proliferating reports urge wholesale change. However, they admitted that improvements in availability and accessibility of care could be made, and that the system, in Dr. Hunter's words, "probably could do with a bit of moulding and adjusting. But I think it should be done on the base of what we have now." Dr. Brady's response to a question about the future GP's role in preventive medicine was interesting: "What do they think we've been practising?" he asked. And there was much enthusiasm around the table for this observation. Even so, the presence of so much and increasing amounts of "self-induced disease", such as accidents and cardiovascular and obesity problems suggests that prev¬ entive counselling work is losing its battle. Indeed the family doctors gathered for this panel dis¬ cussion report it to be a frustrating element of their prac¬ tice. Merely supplying information doesn't really seem to work, but anything more active begins to infringe on the patient's rights. You can't legislate lifestyle. Dr. Sangster made the point, too, that not only should public education by the family doctor be nonjudging, it also should teach about how to use the health care system "because people who know how to use the system today really don't have too much trouble in getting top quality care." The discussion ended with some commentary on the public image of doctors, and, while there was nothing even remotely approaching paranoia on the subject, the panellists agreed that the medical profession had not in general come across too well to the man-in-the-street particularly where economic issues are concerned. The team finally dispersed, and, interestingly enough, most of those who had given up part of their weekend to join it appeared to be headed toward at least some further professional obligation that Saturday afternoon. .
.
.
.
.
.
David Woods' final article in this series, in the next issue of CMAJ, examines the way ahead for the family doctor in
Canada.
910 CMA JOURNAL/APRIL 5, 1975/VOL. 112
