Increasing interest in family medicine

Is high-quality and sustainable health care in Canada depending on family physicians?1 I don’t think so. Among many other factors, it will depend on each medical speciality doing its part. It is certainly time to stop “the idea that family physicians play a secondary role to other specialists”, as family medicine is a speciality in its own right and should be appropriately remunerated.

It is also time to stop the idea of the family physician being the gatekeeper to access specialist care. With the public’s easy access to health care information today, many people know when they need an appointment with a specialist. They should not have to go through a family physician to get that. Also, specialists doing long-term follow-up of serious diseases, one example being annual follow up of breast cancer patients, but even when they see a patient for the first time, should not have to have a referral from a family physician in order to be paid a specialist fee. This only increases the cost for the health care system and the workload for the referring physician.

The loss of the rotating internship in 1993 plays a large role in today’s situation. My voice was not strong enough at the Annual Meeting of the Medical Licencing Authorities of Canada when this change was decided. As a result of this change three serious problems have arisen: : The first is that medical students now must select their future speciality training before they have had any exposure to the various specialities they may choose, and then as a result easily make the wrong choice. The second problem is that PGY-1 does not follow the academic year and therefore makes it impossible to change stream after 12 months. The third problem is to get into further speciality training after you have open your medical practice. One time it was impossible, there are now only a very few openings to somewhat alleviate this problem.

The reason why students from poor neighbourhoods are seven times less likely to enter medical schools is not only a matter of cost, but also a fault of the admission system for medical schools. Applicants can polish their application2 by doing community work abroad, a travel experience that only children of well-off parents can have, and get extra attention on the admission list. Community work in a poor Canadian neighbourhood, which certainly is more valuable for a future family physician, is not valued as equally high.

Also health care terms need to be more defined. What does “high quality health care” means? Currently it seems to mean whatever you want it to. I remember at one time it meant to get “the correct diagnose and the correct treatment at the right time”. I think this definition is sufficient and should still stand. Inclusion of cost or other financial considerations now seem to play a prominent role, although they do not belong in the definition of quality. The assessments of both quality and cost-effectiveness, the latter being a political and very subjective factor, may still be necessary which has so elegantly been described by Phil McFarlane.3

What is rural medicine? The term is very much liked by family physicians and their interest groups. Is every community of less than 10,000 people a rural region? Let us say that a triangular area in Canada has three towns about 15 km apart, each with less than 10,000 people, but with a total population of 20,000 people within that triangle. In one corner there is a hospital with several specialities serving 60,000 people. Is this an area where family physicians should practise “rural medicine”? I don’t think so. This should be called a semi-urban area and the public will not stand for any lower quality of care or less high-tech equipment than there would be offered in a city, nor should they. I don’t think that there is any need for a family physician working within 100 km, or 60 minutes of ambulance transport time, from a hospital with secondary care to practise rural medicine. With this definition of ‘semi-urban’, hardly any physicians in the three Maritime provinces, or very few in Canada for that matter, have to practice true rural medicine because most practise within the parameters of a semi-urban area.

Further no newly-graduated family physician today has had enough exposure to family medicine to be able to practise rural medicine.1 The romantic view, however, still seems to stick with some young physicians that it is OK to go out and to do everything: deliver babies; do minor surgery; look after acute abdomen in a small community hospital without the technical equipment necessary to practise up to date acute medicine. If somebody is going into true rural medicine, they would require a year or two of more clinical training.

Is there a lack of family physicians in our country, or can the health care system and the family physicians’ training and role be reformed to make better use of their skills? Having grown up and worked as a physician in a country where the nurse practitioner was the backbone of primary medicine, it is difficult to understand why the training of this group of nurses has not taken off in Canada. These highly-trained nurses can work independently, but in close cooperation with family physicians, and the amount of work that they can relieve the physicians of, is amazing. There are examples in Canada of how the number of trips to the family physicians in an area served by a nurse practitioner have drastically decreased. The trend now seems to be to inappropriately utilize this group of nurses, whose main education should be in independent clinical work. Instead they are hired as research assistants; as helper in a physician’s office; or employed in hospitals. This type of work can equally well be dona by an RN or an LPN. To use a nurse practitioner this way is a waste of their training.

So where does the family physician fit in, in today’s changing health care system? I think there should be less emphasis on acute care, especially care needing hospital resources. Small community hospitals should no longer try to offer in-hospital acute care or surgery under general anaesthetic. These hospitals should be transformed into hospitals run by family physicians for long-term care; certain types of rehabilitation; and continuation of care after the acute phase of specialist care is over. This will help decrease the pressure for acute care beds in larger hospitals. Various types of community care, public health, and preventive health are also areas not well served. I am sure that the family physicians ,themselves, have a long list of needed services which they currently cannot meet.

So where do we go from here? It is not acceptable any longer to continue to funnel more money into doing the same thing, in the same way. We will never have the ability, nor the funds, to build enough hospital beds or to train enough physicians. The more resources we have, the lower the bar will be lowered for the public to request these resources. There has to be a new way of thinking, a new paradigm. Look outside Canada and find out what other countries have been doing to solve the same problems in their health care system that we, and all developed countries, currently have.

References 1. Avinashi, V, Shouldice, E. Increasing interest in family medicine. CMAJ 2006;174;(6);761-2 2. Johnston, S. Medical training in Canada. CJRM 2005;10(3);183 3.. McFarlane, P. Not all guidelines are created equal. CMAJ 2006;174;(6); 814

Conflict of Interest:

None declared