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COLLABORATION BETWEEN FAMILY PHYSICIANS AND MEDICAL
SPECIALISTS
The Gulf Between Preferred and Actual Practice
Study on the perceptions of medical residents and their
educators of the roles to be assumed by future physicians in
collaborative practice and their evaluation of future physicians
preparedness for these roles
Marie-Dominique Beaulieu, M.D., FCFPC, Professor Doctor Sadok
Besrour Chair in Family Medicine
Department of Family Medicine, Faculty of Medicine, CHUM
Research Centre, University of Montreal
Louise Samson, M.D., FRCPC, Professor
Department of Radiology, Radiation Oncology and Nuclear Medicine
Faculty of Medicine and Centre Hospitalier de lUniversit de Montral
(CHUM), University of
Montreal
Guy Rocher, Ph.D., Professor Department of Sociology and Public
Law Research Centre
University of Montreal
Marc Rioux, doctoral candidate Public Law Research Centre
University of Montreal
Laurier Boucher, professional social worker, MSW, Research
Associate Doctor Sadok Besrour Chair in Family Medicine
Project funded by the Royal College of Physicians and Surgeons
of Canada and and the Doctor Sadok Besrour Chair in Family
Medicine
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This research has received funding from the Royal College of
Physicians and Surgeons of Canada as well as the Doctor Sadok
Besrour Chair in Family Medicine of the University of Montreal. The
project was approved by the Research Ethics Committee of the Centre
hospitalier universitaire de Montral (CHUM) Research Centre. ISBN:
2-9807566-5-2 Cite: Beaulieu M.-D., Samson L., Rocher G., Rioux M.,
Boucher L. Collaboration Between Family Physicians and Medical
Specialists, The Gulf Between Preferred and Actual Practice. Doctor
Sadok Besrour Chair in Family Medicine Montral, 2005. 57 pages.
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TABLE OF CONTENTS FORWARD AND ACKNOWLEDGEMENTS I1. BACKGROUND,
APPROACH, RESEARCH QUESTIONS Everyone wants to head in the same
direction, but where are we actually going?
1
1.1 We have a consensus: A new medical practice will play a key
role in current reforms
1
1.2 A growing gulf between the preferred vision and actual
practice
2
1.3 The professional system: A useful tool provides a fresh look
at professional collaboration in the health care system
3
1.4 Training: Where professional identity is formed
7
Objectives and method 9 2. FINDINGS Training, practices and
career choices that do not always follow the general consensus or
the official view
11
2.1 So what exactly is a family physician?
11
2.2 Collaborate? Sure, but who will do what?
17
2.3 Collaboration can be learned! ... Really?
23
2.4 Summary 27 3. OPTIONS Systemic problems require system-wide
solutions
30
3.1 Respondents proposals
30
3.2 Our proposals 35 424. CONCLUSION 47 APPENDICES TABLE 1
Summary of Discussions on the Nature of Professional Collaboration
and the Issues It Raises TABLE 2 Mail Survey Results, by Residency
Program REFERENCES
48
50
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FOREWARD AND ACKNOWLEDGEMENTS First and foremost, I would like
to take this opportunity to express my sincere appreciation to
everyone who has helped make this report possible. My thoughts turn
first to all the participants, the residents as well as their
professors, who accepted to meet with us and answer our questions
despite their already overburdened schedules. Unfortunately I
cannot mention them by name, since of course their anonymity must
be maintained as a condition for carrying out the study. I am also
thinking of all those who made it possible to conduct our
interviews: the administrative assistants working in various
programs of study and the offices of graduate studies. To all of
these individuals, I extend my sincere appreciation. I also want to
thank the members of the Section of Residents of the College of
Family Physicians of Canada who shared with me their perceptions of
the issues when the study was still at a preliminary stage, and who
helped to organize some of the focus groups. To my research
collaborators who helped me develop the interview protocol and
conduct the interviews and who read the interview transcripts and
attended meetings to review this rich material and identify the
best excerpts, thank you so much. As Principal Investigator, I
would also like to extend a very special thank you to Guy Rocher, a
seasoned sociologist and humanist who has been closely associated
with Qubec history for half a century. Despite his many other
commitments, he accepted to provide me with guidance in my
exploration of a discipline that I have been practicing for over 25
years and that I still love as much as ever. Professor Rocher, your
invaluable advice and suggestions have helped me dig deeper into my
subject, trust some of my intuitions and wander down paths that
might otherwise have gone unexplored. We hope that this report will
be of assistance to all the stakeholders involved in the current
reorganization of our health care system. It provides a better
understanding of the issues faced in family medicine and
specialized medicine and makes an important contribution to the
search for innovative solutions. Marie-Dominique Beaulieu, M.D.,
M.Sc., FCFPC
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1. BACKGROUND, APPROACH, RESEARCH QUESTIONS
Everyone wants to head in the same direction, but where are we
actually going?
Closer collaboration between health professionals is regularly
presented as a key element in plans to provide the public with
better access to high quality services.
But what do those primarily concerned think about collaboration?
Do they share the vision of the role that society wants them to
play? Do they feel
adequately prepared to assume that role?
This study consulted two groups that will have to implement the
current series of reforms family medicine residents and specialist
residents as well as
those charged with preparing them to step into these roles. 1.1
We have a consensus: A new medical practice will play a key role in
current reforms Reforms implemented across Canada are trying to
foster better access to quality care, care that is more continuous
and delivered more efficiently. Better integration of care and a
more judicious use of human resources are two of the preferred
strategies advanced to achieve this end (1), (2), (3), (4). There
is a wide consensus that the success of these strategies will
largely be based on our ability to change current professional
practices. To name just one of the arguments in support of this
thesis, it is worth recalling that a combination of demographic
changes and technological progress has now made managing chronic
illness one of the major challenges faced by the health care
system. Comorbidity is on the rise (over 35% of adults between the
ages of 60 and 69 suffer from at least two chronic health problems;
this proportion is 53% in adults over 80 years of age) (5). We have
a specialized model for the management of clienteles defined
according to specific health problems what is called disease
management but this model is less appropriate for managing
multi-morbidities. We therefore need to develop new models of
professional practice, and a consensus appears to have emerged on a
comprehensive vision of future practice. Primary care services and
family physicians are in a better position to offer comprehensive
care to patients and should be central to this practice. Effective
mechanisms for communication will ensure that information flows
between primary care practitioners and specialized services (6). In
order to ensure that the available expertise is used in an optimal
manner, professional roles will need to change. Medical specialists
will need to stop providing follow-up care to patients who do not
need their level of expertise and concentrate on acting as
consultants (even more than they do currently), providing support
to primary care professionals. For their part, nurses, pharmacists
and other health professionals will take on more responsibilities.
For example, they will need to take on certain
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roles that have traditionally been the domain of the family
physician (1), (7), (4). Recent changes introduced by the province
of Qubec to the law governing health professionals have addressed
these issues, seeking the kind of flexibility that would foster
these transformations (8). Of course family medicine, often
presented as a key element in the new care system, has not escaped
this trend towards redefining and adapting roles (9). In most
industrialized countries, professional organizations of general
practitioners and family physicians have taken clear positions by
adopting a definition of the family physician in which a broad
scope of practice, accessibility to care and continuity of care
have been presented as the very foundations of the profession (10),
(11), (12). 1.2 A growing gulf between the preferred vision and
actual practice There is a vision of future practice a practice
founded on closer collaboration between the various health
professions, which then accept to adapt their roles that is clear
and widely accepted. In the field, however, actual practice does
not appear to be moving steadfastly in this direction. Indeed,
practice is moving in the opposite direction. While health care
systems are ready to make considerable room for family medicine,
the profession does not appear willing to step in and adopt this
vision. The actual number of practising family physicians is in
decline. Medical students are losing interest in family medicine.
Profiles of practice among general practitioners are tending toward
narrowing the field of practice. At a time when there is a general
shortage of physicians, the profession of family medicine has been
particularly affected. The proportion of Canadian medical students
opting to study family medicine was 40% at the
beginning of the 1990s and had fallen to 28% by 2001 (13).
Changes in the profiles of practice of students graduating from
family medicine programs in various
Canadian provinces reveal that a significant proportion of them
(between 10% and 30%) are not offering general primary care in the
first few years of their careers (14), (15), (16), (17). This
proportion is as high as 56% among graduates who completed an
additional year of emergency medicine (18).
In Qubec, an analysis of the billing patterns of all general
practitioners suggests that only 50% have a
practice corresponding to what we understand as family medicine:
25% have restricted their practice to emergency and walk-in care,
and 25% have little involvement in clinical care (19).
During the 2004 National Physician Survey (20), 13% of family
physicians reported that they had
reduced their scope of practice over the previous two years, and
another 25% said that they planned on reducing their working hours
in the following two years.
The situation is no better with respect to collaboration between
family physicians and medical specialists. Concerns had already
been raised in 1993 with the publication of a joint study by the
College of Family Physicians of Canada and the Royal College of
Physicians and Surgeons of Canada. It reported on problems
achieving collaboration between general practitioners and
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specialists, and underscored the existence of negative
prejudices on both sides (21). The 2004 National Physician Survey
indicated that the situation had not improved (20): 33% of
specialist physicians reported that they were unable to see
non-emergency patient referrals
from family physicians in less than three months. Only 25% could
see an emergency consultation within 24 hours.
30% of family physicians rated access to specialists as
acceptable or weak. 50% of specialists qualified access to family
physicians as acceptable or weak. This gap between practices
observed in the field and the proposed vision raises many
questions, particularly when we know that the vision is supported
by leaders in family medicine. How do family physicians, who will
have to perform increasingly complex clinical tasks, see their
scope of practice,1 this key element of the practice of family
medicine? What is their position on having to share their
privileged relationship with the patient in a team setting, where
nurses and other professionals play increasingly important roles?
How do family physicians and medical specialists see their
collaboration and the role that each will need to play in a
collaborative practice? This last issue begs the formulation of new
questions. Until now, for the most part our attention has been
focused on collaboration between the professions. A major
initiative has been launched in Canada, with the objective of
encouraging collaborative practice among professionals in all the
sectors of patient care (22). However, there has been much less
interest in collaboration between members of the same profession,
as if collaboration between physicians is taken for granted. Some
experiments have suggested that this collaboration is anything but
operable, and that developing a collaborative practice between the
specialist and the general practitioner is still very much on the
menu, with all the attendant hurdles to be crossed and therefore to
be studied and understood (21), (5), (23), (24). 1.3 The
professional system: A useful tool provides a fresh look at
professional collaboration in the health care system In order to
examine this new collaborative practice, and in particular the
roles that medical specialists and family physicians will need to
assume, we have adopted the systemic framework developed for the
analysis of professions by Eliot Freidson (25) and Andrew Abbott
(26). This approach takes both a concrete and penetrating look at
the reality of professions and one that we believe is not
sufficiently known among medical professionals, whether specialists
or general practitioners. After giving due consideration to the
general conditions of practice, we decided to bend the law and the
official position by treating family physicians and specialists as
two professions, professions that undoubtedly maintain close
familial ties but that are in practice quite distinct. We will
consider their respective position statements as the official view
of these two professions and an expression of their preferred
vision of practice.
1 In this report, references to scope of practice implicitly
assume the goal of a wide scope of practice in family medicine.
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The family physician (27) The family physician is a competent
clinician (comprehensive approach centered on the patient,
expertise in a wide range of routine problems and in emergencies).
Family medicine is a community-based discipline (practice profile
adapted to the needs of the community; unselected and
undifferentiated problems; varied practice settings; professional
collaboration). The family physician acts as a resource to a
defined population of patients (practice as a population at risk).
The physician/patient relationship constitutes the essence of the
role of family physician (understanding the human condition;
providing continuity; defending patients interests).
The medical specialist (28) Expert Communicator Collaborator
Manager Health promoter Scholar Professional
The professional system according to Abbott and Freidson The
professional system is a collection of institutions through which
members of an occupation can move ahead in society by exercising
control over their own work. This privileged position is possible
because the specific tasks that they carry out are different enough
from those of most other workers that members must exercise control
over their own profession. The two guiding principles of the
professional system are based on the belief that certain tasks 1)
are so specialized that they are inaccessible unless one has the
training and the experience to carry them out, and 2) cannot be
standardized. The idea of specialization, and therefore of
expertise, is the core of the professional system. However, this
concept of specialization is quite relative; someone who is
considered a generalist in a given profession may be considered a
specialist if their expertise is compared to that of other
professions. Within the professional system, each profession is
defined as a function of a group of tasks that are themselves
established by jurisdiction. Each profession must constantly defend
its legitimacy and its jurisdiction, whether in the public arena
(before the general public, institutions and the State) or in the
workplace, the main arena where professional work is negotiated on
a day-to-day basis. This is where professional barriers are most
poorly defined, particularly in times of staffing shortages, when
jurisdictions are most vulnerable and ground can be won or lost. A
disciplines ability to justify and defend its jurisdiction depends
on its capacity to clearly establish its role and its effectiveness
in the resolution of a series of problems. It is through
professional work, the professional tasks carried out by its
members, that a profession can establish its identity, its
legitimacy and its jurisdiction in contrast with the other
professions with which it is constantly interdependent. These tasks
have three bases: objective foundations, subjective foundations and
the ability to manage a system of specific codified or academicized
knowledge.
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Professional identity The objective foundations of a profession
are located outside the professional system and are characterized
by four main factors: technologies, social organization (laws,
institutions, etc.), a natural fact (such as illness) or a cultural
fact (such as aesthetics or spirituality). The subjective
foundations of professional tasks are grounded in practice and are
the most important bases of the profession. Abbott categorizes
subjective bases according to the three major phases in any
professional work: the diagnosis and the treatment of problems, and
the process of inference.
Diagnosis concerns how we understand and classify problems. The
classification system can expose the profession to jurisdictional
challenges. For example, the more a profession restricts how a
problem can be defined, the more it leaves room for another
profession to claim jurisdiction by proposing a more comprehensive
solution to the problem. On the other hand, the more vague the
definition proposed of a problem, the more the profession leaves
itself vulnerable to another profession that would present a
clearer and more precise definition of the problem. Two aspects of
treatment can influence the vulnerability of a professional
jurisdiction: the effectiveness of treatment and its complexity.
For example, the less a profession is able to measure the efficacy
of a treatment, the weaker is the professions claim to provide a
true solution to the problem. The easier a treatment can be
provided, the more it can be routinized and claimed by another
profession. The process of inference that leads to a diagnosis and
associates the diagnosis with a treatment also contributes to
making the profession unique: the more direct the link between
diagnosis and treatment, the more vulnerable the profession
becomes, because its tasks can be standardized and delegated. The
more the process of inference is complex and based on abstract
knowledge and the more the related judgments are discretionary, the
less the professionals position may be considered vulnerable.
Specific, codified or academicized knowledge. Professional work
has direct ties to a system of knowledge. Professional knowledge
gives legitimacy to professional work by clarifying its foundations
and linking it to societys fundamental values, such as rationality,
logic and science. It is through codified or academicized knowledge
that the efficacy of treatments can be demonstrated. Thisknowledge
also leads to innovations that offer the profession some protection
through the development of new expertise. The world of codified or
academicized knowledge is also where future professionals receive
their training. A system of interdependencies Professions are
interdependent. The internal structure of a profession is only one
of many determinants of a professions ability to adapt to upheavals
in the system, which is continually in motion and never remains in
a state of equilibrium for long. These upheavals, the constant
changes that can disturb the professional systems equilibrium, come
as much from the external environment as from inside any of the
systems constituant professions.
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The external environment includes the social environment and the
cultural environment. Among the elements of the social environment
that can disturb the professional systems equilibrium we should
mention changing technologies and the organization of work,
particularly the rise of bureaucratization and the creation of very
large organizations. But according to Abbott and Freidson, the
changes in the cultural environment play an even more decisive
role.2 Their discussion highlights three specific factors: o The
increase in the quantity and complexity of knowledge. Professions
adopt different
strategies to deal with changing knowledge, and these strategies
can have significant effects on their jurisdictions. For example,
the need to manage complex and abundant knowledge may result in the
creation of an expert system. This expert system, however, may make
it possible to routinize certain practices that may then be more
easily taken over by another profession. For example, the
development of increasingly precise practice guidelines undoubtedly
contributed to the development of the role of clinical pharmacist
by enabling pharmacists to maintain that they are now able to treat
patients and prescribe medication.
o Changing social values. Professions base their legitimacy on
social values (what Abbott calls
the currency of legitimation). For example, science and efficacy
are the social values upon which the professional system has
traditionally been based. They have gradually been superceded by
efficiency, accountability and integrity, and this has changed some
of the rules of the professional system. Specialization is highly
valued at the expense of general practice, a trend that harms
family medicine. On the other hand, over the last few years we have
witnessed a return to humanism and community values, a trend that
could result in family medicine becoming more highly valued.
o The rise of universities. Historically, universities had to
work their way into the professional
system, although they now provide most professional education.
The relationship between universities and the professional system
is unavoidable, given the importance of knowledge in professions.
This relationship creates tensions between academics and
practitioners in the same profession; the former set the criteria
of good practice by which the work of the latter is evaluated.
Internal relationships between members of the same profession
One of the fundamental aspects of internal relationships between
members of the same profession is the ability of members to
differentiate themselves from each other, assume a certain amount
of power and establish their own professional or personal path
within a given jurisdiction. This capacity for internal
differentiation offers needed room for member autonomy and the
pursuit of personal aspirations, but it can also become a source of
friction or tension. We will briefly discuss four ways in which
members of the same profession can differentiate themselves from
each other. o Intra-professional status. Since a profession is
organized around a system of knowledge,
higher status is bestowed upon those who are more involved in
the organization of learning and the generation of knowledge. This
can be a source of problems or discomfort for professionals working
in the field. In the eyes of clients and members of other
professions
2 For more information, read Abbott op. cit. Chapter 7: The
Cultural Environment of Professional Development (pp. 177-212) and
Freidson, op. cit., Chapter 7: Bodies of Knowledge (p.
152-178).
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with whom they have daily contact, practising professionals give
the profession legitimacy through their work. Yet within their own
profession, practising professionals generally have the least
status, or at least they hold less prestigious positions than
colleagues respected for their scholarship.
o Differentiation of clienteles. The issue of differentiating
clienteles can have considerable
impact. For example, some specialties or sub-specialties may
abandon certain clienteles, leaving them available to another
profession. Abbott provides the example of nurses, who entered the
field of primary care after it had been somewhat abandoned by
physicians. According to Abbott, internal differences in status,
combined with different clienteles and different ways of organizing
work, can create large disparities in income, power and prestige
within a profession.
o Differentiation of workplaces. Two dimensions are important
here: the issues of income
(whether it is from an independent source or by salary, which
carries less prestige) and type of work (i.e. working in a group or
alone). For example, in medicine the hospital has become an
important workplace, just as health management organizations have
become in the United States. As a result, physicians who practise
outside these structures have lost part of their prestige and
power.
o Differentiation of career plans. Career plans are important
because they can contribute to a
certain demographic rigidity that could make it difficult for a
profession to adapt to changing circumstances. For example,
staffing shortages or surpluses will have an impact on a profession
and its role in the system.
Adopting this analytic approach to the study of collaborative
practice inevitably leads to an examination of the boundaries
between the various professions, but we also need to look at each
professions functions, roles and identity. This last issue is
particularly important, since professionals can only develop
effective collaborative relationships if they have, from the
outset, a good idea of their professions identity and its area of
expertise. In order for collaboration to be effective, one must be
able to establish and assert ones expertise and acknowledge and
respect the others expertise. Interviewing physicians about
collaboration therefore necessarily involves asking them about how
they see their respective role and professional identity. This is
an issue that has become more critical for family physicians at a
time when the available data suggest that they are deeply concerned
about their professional identity. 1.4 Training: Where professional
identity is formed The training of professionals is clearly one of
the factors influencing how the system functions. In health, the
educational system plays a particularly important role in how
professional identity develops (25), (26), (29), (30) and how
professionals learn to collaborate (31). The apprenticeship model
used in medical training in clinical settings has a significant
effect on how physicians internalize professional roles (29),
(30).
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The initial training received by professionals is undoubtedly
one of the main levers for implementing collaboration in the health
care system (22), (32), (33). But even here, observers have
underscored a break between the proposed vision and the reality of
practice in training environments (34), (35), (36). Does clinical
training offer students educational settings and role models that
are appropriate to the modes of functioning we want to emerge in
health care? Do practice training environments enable students to
acquire needed new habits, including learning how to work in a
collaborative practice? Certain programs have already responded to
these issues by introducing changes in direction, putting more
emphasis on the development of learning experiences in the
community, in a rural setting and/or in a multidisciplinary
context. The development of attitudes and aptitudes for
collaborative practice has become one of the stated objectives of
all the organizations and professional orders responsible for
training health professionals. In medicine, the Royal College of
Physicians and Surgeons has identified collaboration and
professionalism as the fundamental competencies required in the
practice of specialized medicine (28). Studying the
professionalization process in medical specialties is not new;
several sociologists and educators became interested in the subject
as early as the 1980s (30), (29). It is nevertheless remarkable
that these studies limited their examination of family medicine to
a strict minimum. This is probably a reflection of the level of
interest for the discipline in health care systems that are
oriented towards specialized medicine. To fill this gap, we
urgently need to know how educators and young physicians reaching
the end of their training (in family medicine and in specialized
medicine) perceive their respective roles in collaborative practice
and, in addition, to have their evaluation of the training they
received to prepare them for these roles. Summary This study has
heard from family physicians and medical specialists who have
reached the end of their training as well as their educators. It
explored how these young professionals perceive their future roles
in a health care system based on collaborative practice, and how
they see their specific contribution to this new form of practice.
More specifically in terms of collaboration between family
physicians and medical specialists, this study also seeks to deepen
our understanding of how various residency programs implement and
attain training objectives related to competencies in collaborative
practice that the Royal College of Physicians and Surgeons of
Canada (28) and the College of Family Physicians of Canada (27)
have identified as priorities.
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Objectives More specifically, the studys objectives were: 1. To
survey training objectives with
respect to collaborative practice competencies in four residency
programs (family medicine, general psychiatry, internal medicine
and general radiology) in Canadas 16 faculties of medicine.
2. To select four of these faculties and
conduct a comprehensive study in order to:
2.1 Explore how future medical specialists and family physicians
reaching the end of their training perceive the role played by
their discipline in the Canadian health care system and how they
see their roles in fostering an effective interface between primary
care and specialized services; 2.2 Determine the extent to which
these future professionals believe that their learning experiences
and their educational institutions have prepared them to step into
these new roles; 2.3 Compare these perceptions with the
collaboration goals in their respective training programs as
defined in the programs official documents and compare these
perceptions with the positions of educators in charge of meeting
program goals.
Method
The study was conducted in two phases that ran from October 2003
to December 2004: A mail survey was sent to each of the
four residency programs in the 16 faculties of medicine across
Canada. The selected programs comprised family medicine and three
other programs that have strong functional ties to family medicine
and primary care medicine: general psychiatry, internal medicine
and general radiology.
A qualitative study was conducted in
four faculties of medicine: Memorial University of Newfoundland;
the University of Sherbrooke, in Qubec; the University of Toronto,
in Ontario; and the University of British Columbia, in Vancouver.
These faculties were selected according to two criteria: whether or
not the faculty had a stated community-based orientation and how
well the final selection would represent the various regions of
Canada.
The project was accepted by the Ethics Committee of the CHUM
Research Centre. In addition, the qualitative sub-study was
accepted by the ethics committees of the University of Toronto,
Memorial University of Newfoundland and the University of British
Columbia.
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The mail survey. A letter was sent to all the program directors
requesting copies of learning objectives for their residency
programs. The response rate varied between 60% and 80%. The
objectives were analyzed by two physician-investigators (M.-D. B.
and L.S.). The analysis was based on the following criteria: The
presence of objectives. The type of objective: whether they were
institutional objectives, i.e. objectives prepared by the
institution itself, or the objectives of the Royal College of
Physicians and Surgeons. The degree of specificity: a general
objective describes a comprehensive skill and a specific objective
describes expectations in more detail. The description: the
objectives were classified according to whether they represented a
targeted general competency or intermediate objectives for
attaining the competency. We also noted if the objective specified
the type of collaboration (interprofessional with a family
physician) that was sought. Finally, the concepts of collaboration
were listed and classified as either traditional (leadership,
understanding of roles, teamwork, etc.) or innovative (communities
of practice, conflict resolution, diversity and tolerance, etc.).
The qualitative study was conducted with focus groups and
individual semi-structured interviews. In order to cover the entire
pedagogical chain, we approached four types of respondents in each
faculty: o The vice-dean of graduate studies
(individual interview), o The director of the program
concerned
(individual interview), o Faculty members from the program
(focus
groups and individual interviews), o Residents in each specialty
(focus groups
and individual interviews).
Residents in family medicine were selected in such a manner as
to ensure representation of the various training environments in
each program. The interviews were led by three investigators (M.-D.
B., L.B. and L.S.). Group interviews were attended by an average of
three specialty residents (out of a possible five eligible
residents) and an average of six family medicine residents. Some
specialty residents were met in individual interviews. Interviews
with professors were either conducted in groups (of three to six
people) or on an individual basis. A total of 40 interviews were
conducted with 91 participants.3 We reached saturation in terms of
the points of view expressed by our respondents (no new themes
emerged in the final interviews), with the exception of radiology,
where the participation rate was not as high. The results are
provided, at times according to the category of respondent and at
other times according to whether the respondents were family
physicians or specialists. Finally, although we selected
universities that would enable us to contrast the results according
to a stated community-based orientation, we found no differences in
the ideas expressed by respondents from these two groups. Our
findings have therefore been presented giving no particular
attention to this parameter. N.B. To simplify data presentation, we
have integrated findings from the analysis of residency programs
with findings from interviews.
3 All the vice-deans of graduate studies and all the program
directors (with the exception of two in radiology) participated in
the study. We met 16 professors of family medicine, 14 specialist
professors, 25 family medicine residents and 18 specialty
residents.
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2. FINDINGS
Training, practices and career choices that do not always
follow
the general consensus or the official view
Differences were found at various levels: between family
physicians,
between family physicians and specialists, between residents and
their educators,
between the official training objectives and the actual training
received, between the vision of the role of each party in a
collaborative practice,
and among ideas on what consitutes collaborative practice. 2.1
What exactly is a family physician? Two interview excerpts provide
a good description of how family physicians (and indeed the
majority of our respondents) view family medicine.
The thing about family physicians is that after they treat
patients, they also do the follow up. They carry long-term clinical
responsibility for their patients, independent of the patients age
(pediatric, adult or geriatric) or the illness. This requires a
wide renage of skills because various approaches are required.
Sometimes family physicians provide curative care, sometimes they
follow a chronic illness or provide palliative care, where the
focus is more on the patients comfort. As a family physician, one
has to be able to move comfortably through all this. In addition,
sometimes you have to defend the patients interests. There are
times when the patient has trouble understanding the system,
knowing where to turn or how to access certain types of treatment
or referrals. The role of a family physician includes ensuring that
the patient has all he may need in terms of treatment. Its like
explaining everything thats going on being able to educate the
patient. (Resident in family medicine) I can see that family
physicians are really the foundation of the family medical system
here. They provide treatment through the medical system. I think
they also act as very strong advocates for their patients. And in
order to do that, in order to have continuity of care, the
relationship with the patient is very important. (Resident in
family medicine)
Generally speaking, scope of practice, continuity of care and
the relationship with the patient formed the core of respondents
definitions of family medicine. In terms of what we heard, there
seems to be a wide consensus among family physicians about the
nature of their profession. Although the view is widely shared, two
different perspectives on the meaning of scope of practice have
been proposed.
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12
Some of the family physicians and most of the specialists we
interviewed define the practice of family medicine on the basis of
the functions of the family physician, and they consider two of
these functions the ability to offer a first response to any
enquiry from a patient and the coordination and integration of the
care experience as the disciplines foundation and core.
I think the basis of family practice is the continuity of care
for the patient, and, of course, thats medical care. But theres a
whole lot of other things that enter into that, including the
social context and the psychological care. But for the most part, I
see family practitioners as providing continuous care, a kind of
first-level entrance care for the patient. (Resident in family
medicine)
Other participants based their definition of scope of practice
on the practice settings: the medical office for routine care, the
emergency room, the hospital, the delivery room, etc. This
representation refers more explicitly to the community dimension of
the profession: it draws attention to the responsibility of the
family physician alone or in a group to respond to all the primary
care needs of his or her clientele and, in small communities, to
respond to the needs of the community as a whole. Respondents used
the term full-service family physician.
So those are my hopes: that we will continue to have family
doctors who will be there advocating for patients both in the
community and in the hospitals and nursing homes, doing obstetrics,
totally involved in all aspects of patient care. Because I do
think, both economically and personally, that that's the best way
to provide care for the whole country. (Family physician
educator)
There are therefore two ways to look at the practice of family
medicine, or the daily application of this understanding of the
discipline as expressed by a majority of our respondents (scope of
practice, continuity of care, relationship with the patient). But
independent of the criteria respondents used to define their
professions, the interviews revealed another split, one that
appears to be both more significant and more revealing. Ambivalence
about scope of practice: the siren call of specialization Although
the majority of participants stated that a wide scope of practice
is one of the fundamental characteristics of family medicine
(effectively agreeing with the dominant professionnal view), their
responses also very clearly revealed an enduring conflict between
scope of practice and expertise. This conflict, which captures the
tension between family medicines holistic approach and the strong
trend towards specialization in medicine and, more generally, in
society as a whole, was conveyed through many questions and
doubts.
It is a huge scope of practice. Which is one of its biggest
advantages, but, at the same time, its always possible to do a
little too much. Divide yourself in too many different ways that
sacrifice your personal life, aside from medicine. Such as
attending to patients, being very conscientious, and doing
emergency shifts. (Resident in family medicine)
For me, at this point in my training, its expertise as well. Its
just to be feeling that Im able to do a good job at everything. And
I honestly dont feel that I can stay on top of it all, theres
something that has to be cut. (Resident in family medicine)
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13
I think part of that is for fear that its becoming so
complicated that its hard to maintain your competencies.
Subdividing family medicine into family medicine, obstetrics or
whatever. But maybe thats what the future holds. Well, were already
doing that to some degree, there are a lot of examples of how were
all already choosing a particular area of focus. However, I think
in the training program we still kind of encourage people to be
generalists. I think theres a group of people who go into family
medicine because they see a holistic aspect related to health and
human beings, one that is lost in a specialists procedure on a
coronary artery. Maybe there should be a sub-specialty of holistic
family medicine. (Educators teaching family medicine)
These doubts and this questioning leads future family physicians
to conclude that the legitimacy of a specialist will be more easily
won than their own, even if they believe that their functions as
first respondent, coordinator and integrator are critical to the
health care system.
I had specialist friends who said, Youre just in family
medicine. I said, But I have a much broader range of skills than
you. I will be able to deliver a child, care for a grandfather or
treat depression In a university hospital, family medicine has had
a really bad rap. (Resident in family medicine)
For all intents and purposes, to hear it from family physicians
whether residents or educators the degree of recognition accorded
to specialization represents a thorn in their sides and a constant
source of concern. Some of them mention the extent of current
knowledge, the way the health care system is organized and their
life objectives, and simply conclude that it is impossible to
sustain such a wide scope of practice. Even those who say they are
comfortable with a status as non-expert acknowledge the importance
of being an expert in something.
I am feeling a little bit overwhelmed by all aspects of family
medicine. Therefore, I want to specialize. I am considering
obstetrics, and annual family follow-ups, and probably palliative
care. I do have adults in mind, I dont exclude them, but I would
probably try to focus as much as I can on a specific population.
Because doing everything just seems too much. Considering my
ability to absorb information, I think that I could be a specialist
instead of doing everything. (Resident in family medicine) We are
supposed to know everything. That is what our teachers are telling
us. Yet, the movement is towards specialization. And I understand
why My whole goal since being in internship has been to try to
figure out what it is Im going to eliminate from my practice, and
what Im going to practise. Thats been my goal: it hasnt been about
keeping all my skills, but trying to figure out how many to lose.
(Resident in family medicine) You just need to see both sides. No
one nowadays can be a Jack of all trades. You have to maintain your
scope of practice, but not be excessive about it. (Resident in
family medicine) Were generalists. But we also have an opportunity
to be a little bit of a specialist while being a generalist. And I
like that idea. I like the idea of knowing a little bit more about
an area because, as you said, we know a lot of things. But, you
know, theres just no time. (Resident in family medicine) In fact, I
think the subtle message out there is still that if youre not doing
comprehensive care like what you might see in a rural community,
youre not a family doctor. (Program director)
Finally, and still on the same theme, some respondents were
concerned about the trend among departments of family medicine to
introduce third-year specialized programs:
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14
We are concerned about a trend in training in which departments
seem to want to develop what I will call the specialized family
physician. We have also noted that many family medicine residents
have a tendency to develop an area of expertise. In my opinion,
this is a misreading of the mandate or our definition of the family
physician, who is someone with a wide scope of practice, not
someone with a narrow or focused practice. I sense there is a
movement in this direction, and I am afraid that we are heading in
the wrong direction, forming not family physicians but specialized
family physicians (Vice-Dean)
An enthusiastic commitment ... that we would just as well put
off for a bit This tainted ambivalence that one would maintain
between scope of practice, an ideal that is often considered
unattainable, and expertise, a source of professional prestige, is
in some ways reflected in how residents view their entry into the
profession: with an enthusiasm that is tempered with a certain
prudence. Family medicine residents, well aware of the current
staffing shortage, feel that they enjoy considerable freedom as
they set out on their professional careers. They are proud to be
family physicians and appreciate the diverse types of pratice the
profession affords. Given their levels of debt, financial
considerations figure strongly in their choices. Family medicine
residents see two career streams. Some of them immediately begin a
career in a practice setting where they plan on having a career.
For example, this is the case among residents who set up practice
in more remote regions, particularly in British Columbia and
Newfoundland. They are planning a very diversified career and opt
for group practice. Others, a larger group, see the start of
practice as a point of transition. They do not want to commit to
working with a specific clientele, a group of colleagues or a
community. Such a commitment is made even more difficult by the
fact that they still do not have much stability in their personal
lives. They therefore prefer having the flexibility to be able to
try out several models of practice and to consolidate (not lose)
the hard-won skills demanded in hospital and emergency
practice.
In my first year of practice Im going to be on a very steep
learning curve. Ive chosen an environment where I dont have to
actually learn a lot about billing, either. Focusing on clinical
medicine is exactly what Id like to do, and not worry about the
business aspect of billing. I went into medicine because I like
people, not numbers and that kind of thing. (Resident in family
medicine) The piece of advice a family physician keeps giving me is
you just keep adding on as you go along, and I think thats what Im
really going to try to do when I start out: start out small and see
fewer patients and then, if I want to add, I can. Im definitely not
in a rush to check into a practice because I know how hard it is to
relocate. So Im going to stay local for a while. (Resident in
family medicine) You have to figure out for yourself what you want
out of life, out of your practice, out of your different
activities. Once these are established, then youre able to present
it to your group and explain it according to the situation, taking
into consideration not only your realities and limits but those of
your community and the area in which you live and practise.
(Resident in family medicine) Because of all those unknowns, Im
kind of torn between the decision to just take something thats easy
and thats already set up, versus going for something that I think I
would like better but having to deal with all the starts And also I
think reimbursement is a big issue in terms of starting up your own
practice. I mean, youd have to see enough patients, working on a
fee-for-service basis, to actually pay the bills and make a salary,
as compared to people who go into walk-in clinics where
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15
things are all set up for them and they can see more patients
with less complex problems and walk away with a better pay stub at
the end of the day... Also, finding the right person to share a
practice with is another big issue. Would we be compatible? How
would that work? Would the patients who start out with me be
comfortable seeing the other person when Im not there? Those types
of issues. (Resident in family medicine)
Changing values and aspirations across different generations of
family physicians Finally, this discomfort within the profession of
family medicine has opened another gulf, this time between young
physicians who embrace the profession and physician educators who
seem to have difficulty letting go of the traditional view of
family medicine. Several residents therefore feel judged by their
elders and their professors and report that the latter adopt a kind
of doubletalk. On the one hand, what family medicine educators say
encourages students to find a balance between their professional
and personal lives. But in fact the residents sometimes have the
impression that they disappoint their elders and their professors
when they decide to restrict their practice. Generally speaking and
in contrast to their professors, the residents do not have the
feeling that there is a crisis in family medicine. Some of them
feel guilty, or at least uneasy and torn between two sentiments: a
sense of responsibility to meet a societal need and fulfil the
vision that the discipline has of itself and a sense that it is
impossible to do it all, to incarnate the entire discipline in
their individual practices.
This happened in just one day. I literally had a talk with a
doctor who works part-time in palliative care and kind of feels the
same way I do about family medicine. And in the same day, another
who works in palliative care was quick to say, Those hobby doctors,
they just arrive and theyre just a hobby doctor, and they want to
make the big bucks. But they dont want to work, they want to work
part-time, and no one is getting their work done... Within the same
day, Ive been told, This is how I chose to do it and why. I also
realized that I will always have to deal with people who are
thinking that Im not doing enough work. (Resident in family
medicine) A lot of the supervisors we work with are sort of stellar
family physicians who do a lot of things, who cover a lot of areas
in their practice. And I, for one, feel a little bit guilty when
they ask me what Im doing next year and I say that Im going to do
OB and palliative. I feel they are disappointed if I say, Oh, Im
going to work in a clinic or do some walk-in shifts... Heaven
forbid walk-in! Thats sort of the subtle pressure: Oh, thats
nice.... (Resident in family medicine)
I think theres also sort of a subtle pressure to get new family
doctors to practice in comprehensive care, and we want this balance
in our personal life. I feel there is pressure to do more than just
family medicine, like youre not living up to expectations if you
dont practice in some other area of medicine like palliative care,
emergency or obstetrics or that sort of thing. (Resident in family
medicine)
For their part, professors also note this generation gap. They
speak of a deep commitment to their discipline. Several of them
seem to be watching, powerlessly, as their graduates lose interest
in the model of the complete family physician. They speak of it
with some regret and sometimes with bitterness. They perceive this
generation gap as a conflict of values.
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16
One of the reasons Im in family medicine is because of that: be
a holistic physician and get to know people at various levels of
their experience. And I see it as a challenge to try and inspire
students to continue to hold on to that vision at the same time
that were spreading out their duties over a larger group of people,
both specialists and other health professionals. I think its
important that someone keeps up with all that. I see it as a
challenge, because those of us who are teaching are all strong
believers in comprehensive family medicine, and a lot of the
residents who come through are not interested in comprehensive
family medicine. And thats a challenge too, to teah people who do
not share your vision. (Family physician educator)
Fortunately, there is always the relationship with the
patient... Unable to define themselves in terms of a specific
expertise, the traditional way professions define themselves,
family physicians fall back on what is generally considered one of
the basic characteristics of their profession: the relationships
they establish with their patients. This serves as an anchor for
all our respondents in family medicine, both residents and
professors. Family physicians find their raison dtre in the
relationship with the patient.
The most exciting thing is being able to practise medicine one
on one, being able to have a patient of my own, who I follow and
get attached to, and he gets attached to me. (Resident in family
medicine)
I think thats part of why you choose family medicine, as opposed
to people who choose gynecology or surgery. I really do, I think
theres something about wanting to please people. Thats partly why
we choose family medicine. We love to be near people and then
seeing tangible small-scale results. Theres a relationship, a bond,
and thats probably important to us. (Resident in family
medicine)
However, here again the position is partly ambivalent and tinged
with paradox, because if the relationship with the patient is the
main quality in the practice of family medicine, it can also be
peceived as a burden.
I think one thing about family medicine is that you have
long-term commitments to your patients, which can be scary as well,
because youre worried about picking on patients you may not like.
(Resident in family medicine)
Has family medicine reached a critical threshhold? All the
physician educators interviewed, whether generalists or
specialists, spoke of a crisis or of danger. Several family
medicine educators spoke of the profession as an endangered
species.
My fear is obviously that we wont have family medicine in ten
years, that it will be all specialists or GP-specialists. In other
words, that GPs would pick out different disciplines that they
would specialize in, but nobody would be doing the whole scope of
family medicine. Which is very scary for me, someone whos probably
going to make more and more use of the system over the next ten
years... (Family medicine educator)
However, others pointed out that the situation plays out
differently depending on whether your practice is in an urban area
or in one of the regions.
In the city I see family physicians tending, for a variety of
reasons, to move away from full-service practice and into more
focused practices, leaving the continuity aspect of care, or, if
you like, certainly
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17
the comprehensive aspect of care. I see patients having to spend
more time in emergency rooms and walk-in clinics in order to get
primary care. So that is a very general statement about the urban
environment as I see it. Thats not to say that all family doctors
are moving in that direction, but increasingly it seems that its
very difficult for a variety of reasons for family doctors to
provide the old traditional broad-based family medicine service.
And that stands in sharp contrast to family physicians working in
rural and regional communities where family doctors do the whole
range of family medicine, including intensive care and emergency
medicine, and in some small communities where family doctors do the
whole range of family medicine plus anesthesia or advanced
obstetrics. So I guess I see an evolution in two streams: one is
increasingly focused and the other is, in a sense, increasingly
broad: that is, in rural communities, as specialists tend to be
either forced to rotate or are voluntarily rotating through larger
concentrations and larger communities. (Family medicine program
director)
Others are of the opinion that family physicians are condemned
to an impossible practice, noting how little the profession is
valued in the health care system. Do we expect too much of the
family physician?
Its a very high level of responsibility to feel that you are
responsible for all aspects of your patients health and that you
will be held responsible for it. So when your patient shows up in
emergency with an MI and its deemed to be because her LDL wasnt
brought down to 2.0 and her HbA1C was over 0.07, you know, just how
much responsibility can you take for it? And yet, that is sort of
how the family physician is being viewed. I think people are
feeling that its not appropriate to shoulder that kind of
responsibility, and they dont want to. (Family medicine program
director)
Finally, many respondents believe that the trend towards
specialization among family physicians represents the real and
principal danger to the professions survival, because the system
has a vital need for an integration function, and up until this
point this function has been fulfilled by family physicians. If
they stop performing this function, someone else will have to step
in and take their place. 2.2 Collaborate? Sure, but who will do
what? Generally speaking, the respondents acknowledged that the
question of collaboration between family physicians and medical
specialists was not a problem that captured their attention.
Collaboration is taken for granted. The professions may rub elbows
and respect each other, but they are moving down parallel paths.
Even though all family medicine participants reported positive
experiences with collaboration, their experiences with specialists
were generally quite negative, and vice versa. Family physicians
and specialists generally share a common understanding of their
respective roles, but their views indicate a certain frustration
with respect to how this role is performed. Respondents spoke of a
growing distance between the two professions in terms that revealed
ingrained prejudices on both sides. 2.2.1 Similar notions As we
will see below, the interviews with participants revealed several
inconsistencies between the official view and actual collaborative
practice, yet, contrary to what might have been expected, these
differences are not rooted in disagreement about the nature of
their disciplines.
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18
The specialist: a consultant Generally speaking, the two
professions appear to agree on the role of specialists: physicians
treating patients with complex problems, facilitating access to
specialized services, providing information and acting as educators
and consultants. In collaboration between the two professions, it
is the specialists role as consultant that comes to the fore. It
was the psychiatry residents who best expressed this idea:
When I discharge a patient and he returns to his community, I
have to ask myself how his family physician is going to handle it.
Its clear that in this situation my team and I have a training role
to play, in addition to maintaining a certain presence in the case.
We send the patient home, but if there is any doubt or any type of
problem arises, we are still there, because yes, there are risks.
(Resident in psychiatry) Because the childrens hospital is a kind
of unique resource, my part is more doing the consultation, feeding
back recommendations to the family doctor, and then, maybe, doing
more intermittent follow-up, like in three months or in six months,
and checking to see hows the plan going, making adjustments to the
plan. Not doing the actual, immediate follow up. And then, with the
community mental-health team, I think theres also a role where I
try to do some kind of training and try to export some of the
actual treatments. (Resident in psychiatry)
The family physician: the quarterback of the health care system
The specialists notion of family medicine is essentially the same
as how family physicians see their discipline, including doubts
about whether it is actually possible to fulfil the role in
practice. Most of the specialist physicians interviewed, both the
residents and professors, feel that it would be impossible to
provide the public with medical services without family physicians.
The family physicians expertise in evaluating and managing a braod
variety of cases is widely recognized. The functions performed
(accessibility to, continuity of and coordination of care) are
considered vital. Specialists also acknowledge the unique
relationship between the family physician and the patient, a
relationship that is built up over time.
Obviously, there are two different roles, and those two roles
are equally important. The family doctor is, from my angle, a
primary health care provider who looks after all the primary health
care needs of his or her patients. As I interact with family
doctors as a specialist, I look at them as being quarterbacks. The
family doctor controls the overall care of the patient. In other
words, he may receive expert advice from a consultant or whatever,
but Im talking about the ownership of that patient, the primary
care provider, the person who coordinates all the health care
provided to an individual: its the family doctor. (Director of an
internal medicine program) The core business is really the
presenting physical complaint, or any complaint, in the context of
their family and general environment. Then, once you make that
decision, as to where the issue is, you as a family physician may
not have time to pursue it. (...) So, what I would see as the core
of family medicine is really what is inherent in the name. One
thing is continuity of health care. As specialists, we are not in
that business. They are the hub, in my opinion, of the health care
system. We, as specialists, are the spokes. We go into the various
spokes. The hub of health care provision, in my opinion, is
continuity of health care. (Vice-Dean)
Compared to what we do, I think theyre experts in communication,
and thats a good idea as it relates to their patients because we
(the specialists) have the luxury of being able to focus on an
issue, a specific issue, for the most part. But the family
physician has to deal more with the patients and their
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19
problems in the context of their lives over a long period of
time. He has to take the time to build a relationship thats
therapeutic, a relationship of trust And you come to admire them
for their tolerance and their patience. I think thats what they do
very well. And we could learn from that. (Resident in internal
medicine)
I have always said that I have great admiration for family
physicians, because in order to do what we ask of them, they must
retain an enormous amount of knowledge. You have to be good in
cardiology, in pneumology, in gastroenterology, in obstetrics, in
infertility, in this, in that.... Its incredible! In fact, the
scope of medical knowledge has become enormous. And we are asking
people to master it all... (Vice-Dean)
Other specialists presented a different point of view.
I dont think everybody should be doing everything. So I dont
think the physician should be delivering babies, seeing children,
looking after an infarctus, going to assist surgery... I mean,
theres a reality that has to be faced: you need to divide your
time. And I think that within a family practice there are people
who have technical needs, there are people who have psychiatric
needs... So I think that family practice trainees should gear their
practice, to a large extent, around their interests. But once their
interest areas are defined, then I think they should be
concentrating on an area that has some component of another area.
(Specialist in internal medicine) I come from a different
perspective because I trained in the United States and practised
there as a general internist when I did primary care. So I have
bridged the gap (between primary and secondary care) myself. I took
care of the patients when they were in the hospital and I followed
them as out-patients. (...) I think that in terms of taking care of
adult patients, its a far better system. (...) But its not the way
the Canadian system is set up. Its just a different philosophy
about how you do things. But there is no doubt that theres a
gigantic lack of continuity between what happens in the hospital
and what happens when people go to their family doctors.
(Specialist in internal medicine) I see family medicine as quite
beleaguered. Burdened. And the burdens are multifold. One is that
urban family practice, in my opinion, has shifted, and it has
shifted because there has been a movement in the specialties to
fragment. We have become more and more sub-specialized. And so the
practice of family medicine in an urban center consists mostly of
doing assessments and dispatching, which I think is not as
rewarding to physicians. In the rural areas, we have the opposite
problem. The specialists arent available, so family physicians are
burdened with having to do too much because they dont have access
to the many levels of specialties. (Vice-Dean)
At this point of our report, it is important to point out that
the specialists we interviewed often see themselves as powerless
observers of the identity crisis in family medicine. Even though
they are affected by its repercussions, they do not feel implicated
in the search for solutions. They only ask thenselves where family
medicine is heading.
I think that there are probably all sorts of federal policy,
monetary and financial issues... But there is a crisis. I have the
impression that family physicians are trying to reposition the
profession in terms of the nature of their work, but they are
confronted with all sorts of problems that set them off on
tangents, targeting very specific approaches. I dont quite know how
we are going to get out of this mess... (Vice-Dean)
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20
The wait-and-see attitude towards the condition of family
medicine and the lack of interest in participating in the solution
that we observed in our interviews with specialists was confirmed
by a family physician in a strategic position.
Theres no incentive for specialists to change. I dont think that
they would want to change, and, in the current system, there would
be no real motivation. I dont think they feel any altruism toward
the system or toward primary care, or any personal responsibility
to make it easier for family doctors. (Director of a family
medicine program)
2.2.2 but somethings holding things up There does not appear to
be a major disagreement on the roles that each profession should
play in the health care system, working in the field; on the other
hand, collaborative practice by the two professions runs up against
certain obstacles and does not always meet expectations. Issues
were raised about responsibilities, expertise, family physicians
distancing themselves from the hopsital setting, and changing roles
(see Table 1). Responsibilities: before they can be shared, they
must be divided up It was the specialty residents who had more
perspective on the issues posed by working as consultants in
collaboration with family physicians.
In my two years as a senior resident, what I learned was how to
be a good consultant. It isnt easy. Particularly in internal
medicine, where we want to do it all, control everything, while the
consulting role is about learning to be clear in our oral and
verbal communication, to let people make their own decisions while
offering alternatives. I have seen practices where people didnt
collaborate very well. In addition to this being a problem in
itself, it makes people in primary care afraid to act: they want us
to do everything. In other settings, we are able to talk to the
family physician, even if he or she doesnt have our level of
knowledge in this specific area. When they did have enough
knowledge, they could discuss this or that aspect that we hadnt
seen, as colleagues. We didnt try to impose on them, do whatever we
had to do and just leave them with the paperwork. When the family
physicians knowledge was incomplete, we explained things, knowing
that there would be less need for our input the next time around.
(Resident in internal medicine) Family doctors must realize that,
when we do write back to give them advice, we expect that the
advice will be heeded. We do appreciate it when we send our advice
in the form of consult letters to family doctors and the advice is
recorded and recognized. So I think that the family doctor and the
specialist must work together as a team, but we do have different
roles. (Director of an internal medicine program)
Once again, it was the psychiatry residents who had the clearest
idea of the kind of expertise that the family physician has and
needs. In the relationship they establish with the family physician
the latter assumes the role of manager of patient care and the
former acts as a consultant the psychiatrists particularly
appreciate two aspects of the family physicians expertise: their
mastery of physical medicine and their knowledge of the
patient.
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21
Specialists are particularly frustrated by certain situations
with or attitudes held by family physicians: when they see that the
patients health has deteriorated while in the care of a family
physician, when their recommendations are not followed and when the
family physician is seen as being cavalier in his or her approach
to making the consultation request. But the main problem for these
residents has to do with their responsibility. Even though they
feel mutual respect and trust are very important, they believe the
question of professional responsibility lies at the heart of
collaboration. In order to collaborate, professionals must be able
to clearly distinguish the responsibilities of each party.
Participants identified two fundamental dimensions: availability
and expertise. Availability. Both professions raised the issue of
availability. The specialist, particularly when dealing with frail
and unstable clienteles, wants to be sure that the family physician
will be sufficiently available and have the resources to provide
follow up care. The family physician wants to be sure of having
quick access to the specialist for an opinion and, if required, for
a hospital admission. Otherwise the result is the same: the
physician is stuck with the patient and must carry the
responsibility. Expertise. Rare was the specialist physician who,
when asked about the nature of family medicine, raised the issue of
a lack of expertise as one of the professions limitations. On the
contrary, most deplore the trend toward restricted scope of
practice, which paradoxically results in specialist physicians
providing primary care. On the other hand, expertise comes up again
as a key issue when they talk about conditions for effective
collaboration between specialists and family physicians. They also
mentioned: Conditions of practice for generalists:
Actually, its getting more and more complicated, and it may be
that general practitioners will have to refer more, and certainly
to interact more with specialists. You feel the pressure on primary
care, and it raises questions about their capacity to do everything
in the time they are given. (Resident in internal medicine)
Quality standards that appear sometimes different from their
own:
The other issue with general internal medicine is oftentimes
they refer a specific problem to us, so we investigate it further.
And in the process of doing the history and physical theres another
issue that needs to be dealt with or some unexplained weight
loss... And I find that a little surprising sometimes, to be
honest, that a really obvious physical finding might have gone
undetected, or the potential implications of it were not
identified. And the other thing that Im a little bit concerned
about is whether or not there are slightly different standards as
well, depending on where you are. (Resident in internal
madicine)
Training issues, particularly with respect to the knowledge
needed to follow the great chronic
pathologies such as heart failure and mental health problems. I
think that we have completely unrealistic expectations about what
family practice doctors should be able to do. (Specialist in
internal medicine)
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Specialists isolate themselves These criticisms of others
shortcomings are not just a one-way street; family physicians also
have grievances about their specialist colleagues. They perceive a
certain arrogance in the attitude of these experts and mention
problems gaining access when they need an emergency consultation.
Most of them complained of the profession being somewhat closed.
The specialists did not deny that these complaints could have a
basis in reality. Several of them mentioned a lack of resources in
specialized practice (staff shortages) and some hospital
restructuring policies as important factors in specialized
physicians pulling back and isolating themselves. This phenomenon
can take several forms: collaboration with primary care is not seen
as a priority, specialists do not feel that they need to answer to
primary care, clinicians are exhausted, and the available
specialized resources do not meet the clinical needs of their own
patients. To this must be added ineffective communication systems;
several specialists pointed out that hospitals often begin their
cutbacks in communication support services.
We dont have a good system for communicating whats going on in
the hospital to the family doctors. And a good hunk of that is our
fault, I dont doubt it, because its a time-consuming process to
track down the family doctor, you know; theyre busy, theyre not in
the office when you call them, they call you back and you cant
remember the specifics. You know, its a very tedious process and
not very many of them come into the hospital anymore to see
patients. (Internal medicine specialist)
Far from view... The notion of a certain distance appearing
between the two professions was most strongly expressed by
educators in the specialty disciplines. They mentioned and often
deplored the fact that family physicians have pulled away from
areas where they, the specialists, continue to practice. This
estrangement has been as apparent in urban hospital practice
settings as it has in training environments. Family physicians have
progressively abandoned hospitals to practice in the community. As
a result, they no longer rub elbows with medical specialists, who
work first and foremost in hospitals. Indeed, specialists highly
value hospital work, as hospitals are important centres of higher
learning and specialized practice.
And thats whats been lost by the family doctors leaving the
hospital environment. For all the time they used to see their
patients in the hospital, used to assist on their own surgeries and
everything, they developed relationships with specialists. They had
that. (Family medicine educator)
A slightly cynical specialist added:
Their patients go to hospital, and they are the champions of
continuity of care, but when their patients hit the door here, for
the most part the patients dont have continuity of care. When their
patient is discharged, they dont seem to pick up the continuity of
care. (Specialist in inetrnal medicine)
The domino theory Participants said they had seen a shift in, a
new sharing of, even confusion over the respective roles of
specialists and family physicians. For the most part they
attributed the change to current medical staffing shortages. They
described a paradox in the form of a domino effect: specialists are
leaving certain specialty areas vacant, retreating into
overspecialization, while family physicians are abandoning primary
care and assuming more and more of the responsibilities that
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have traditionally been the domain of specialists. But there are
times when the opposite is true: specialist physicians will invade
a traditional area of practice of family medicine. There is,
however, one point in common: each group deplores the fact that the
other is not playing its role.
I have noticed the staffing shortages. It is a situation that we
have already seen in the more remote areas, but it is now spreading
to other regions. The shortage causes a shift in roles: the nurse
wants to become more of a clinician, family physicians want to
become more specialized, and specialists want to specialize even
more... (Family medicine educator) We are now in what I would
qualify as a major crisis. Were putting out fires: family
physicians are mainly providing specialized services because we
dont have enough specialists. For example, we only have one
endocrinologist for an entire territory, so family physicians are
taking care of the diabetes clinics. And they do it very well; they
have developed very good expertise in that area. But while they are
doing that, they dont have the time to follow patients in the
office. Accessibility in primary care? Its unfortunate for the
patients, but they have problems finding a family physician. They
cant get access as fast as we might want. (Family medicine
educator) There seems to be little commitment on the part of many
of the specialists to facilitating the care provided at the primary
care level. The specialists are spending a lot of time doing
follow-up care that probably should be handled by family doctors,
and could easily be handled by family doctors, and it consumes a
great deal of their time. What we need is access or consultation,
new consultation. And I dont know if they do this because theyre
reacting to the fact that many family physicians arent willing to
follow these problems, or because there are financial incentives
because its simple to do follow-up care and much more difficult to
take on new patients. But thats whats needed in the system, so
perhaps they need to be compensated differently, one that would
take away the incentive for routine work and let family doctors do
that and be available for administration. Thats what we really
need. (Family physician) I think the most important group, the most
important job in medicine is family practice, primary care. Not
because I did it when I started out, but because thats the really
important job. That has to be the sole way to integrate care, and
it doesnt happen. Maybe for a variety of reasons. (Internal
medicine specialist)
2.3 Collaboration can be learned! ... Really? Here again we had
a consensus: collaborative practice between family physicians and
medical specialists will not be possible if practitioners in each
of the professions have not been trained for it. The academic
community appears to be very aware of their responsibilities in
this area, since all the programs we studied comply with the
directives of the Royal College of Physicians and Surgeons and have
objectives with respect to collaboration competencies. But setting
objectives is different from meeting them, and in the case of
collaborative practice, our respondents believe that this
distinction persists.
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In theory, vaguely stated intentions All the programs that
responded to the mail survey had established collaboration
competency objectives.4 For the majority of them these objectives
were institutional, meaning that the program had written its own
objectives as a function of institutional needs. The majority of
these objectives identified terminal competencies rather than
specifying intermediate objectives that would lead to these
competencies. The objectives were generally based on traditional
concepts, with little in the way of innovative concepts of
collaboration competencies. More specifically, if there was
specific mention of collaboration with multidisciplinary teams,
very few institutions made explicit reference to direct
collaboration between the specialist and the family physician. Only
four internal medicine programs and three programs in psychiatry
listed it among their objectives. References to relationships with
the family physician were usually found in the context of medical
specialists responsibilities in the training of generalists rather
than in a context of a collaborative relationship. The objectives
therefore did not indicate notions such as community of practice,
the sharing of knowledge, conflict resolution, the delegation of
medical acts to other health professionals, multiprofessionalism or
interprofessionalism. The objectives were often succinct with
little in the way of detail, leaving one to assume that professors
and residents are able to perceive clear and unequivocal
expectations without precise indications of what is needed in their
particular specialty. The analysis therefore revealed that
educational objectives are not very explicit in terms of
professional collaboration. For all intents and purposes,
consultation is the only collaborative activity between a family
physician and a medical specialist for which teaching has been
formalized. It should nevertheless be mentioned that the physicians
teaching these programs appear to be aware of these shortcomings
and limitations. One of them effectively summarized the view of
everyone we met: We pay lip service to collaboration. In practice,
collaboration left to its own devices The residents we interviewed
had not had formal experiences of collaboration between future
medical specialists and future family physicians. They interact
when they are on call (generally known as the junior/senior
relationship). Together, they survive the training experience, this
common ordeal that at least helps break down their prejudices.
According to residents, professional collaboration is generally not
a formal part of the clinical rotations experience, with the
exception being training programs in psychiatry. When professional
collaboration is explicitly discussed, it is collaboration with
other professions rather than collaboration between family
physicians and specialists. Collaboration is therefore learned on
the job: for example, during hospital rotations. Experience varies
in family medicine; the residents who spoke of being exposed to
collaboration with other professionals who were doing rotations in
innovative training environments. 4 Detailed results from the mail
survey are presented in Table 2.
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Pointing fingers at university hospitals Where the training
takes place appears to play a critical role in learning
collaborative practice. Residents have the perception that
collaboration with primary care is not a priority in university
hospitals. Generally speaking, the family physicians we interviewed
(residents and educators) were very bitter about their
relationships with medical specialists in university hospitals, so
bitter that they had difficulty taking some distance from the
subject. In almost all the specialized rotations, family medicine
residents said that they heard their specialist supervisors make
offensive comments about the clinical conduct of community-based
family physicians, comments often made in the presence of residents
in specialized medicine. All of them said that at one point they
had heard certain specialist professors denigrate their career
choice.
Family medicine is not well regarded anymore, and I think a lot
of it starts early. In the education system, we are taught by
specialists. You dont see family physicians, you dont have any role
models when you go through training. (Resident in family medicine)
Specialists dont respect family doctors, you see it all the time.
Were in a medical school thats meant to produce family doctors,
thats the model of our medical school. But were taught totally,
entirely, solely, by specialists, except probably for a month-long
token visit by a family doctor. (Resident in family medicine) The
family physician must be key, the central person for anyone
entering the health care system. Unfortunately, this role is
scorned in university hospitals because there are just too many
specialists. The situation seems to be better in the regions.
(Resident in family medicine)
Rotations in the regions generally seem to escape this pattern,
offering positive role models to residents in both family medicine
and specialized medicine:
I am in a region. I find that during a rotation, residents
really have a chance to get to know and work with specialists.
Here, as family physicians, we have very close contacts with the
basic specialties, including surgery, pediatrics and internal
medicine. Residents have the same experience when they start
rotations. They have clinical responsibility for patients for
example, when patients are hospitalized and if they have a problem
they want to discuss, they call the specialist in internal medicine
directly. The specialists in internal medicine, like all our
specialists, are very open to direct contact with residents. Even
in Emergency, when they want to admit a patient, they will call the
specialist or the family physician directly. Even for specialty
residents who do rotations here, its a good experience because they
dont often have the opportunity to see this kind of teamwork
between family physicians and specialists, with a case management
role for the family physician and a consulting role for the
specialist. For residents, the best way to learn to collaborate is
to do it during their clerkship. (Family physician educator)
Not being familiar with the training of other physicians Perhaps
what we have just seen in the preceding discussion is one of the
factors that has led the majority of family medicine programs to
pull their students out of rotations in overspecialized
disciplines, deciding that this training is not appropriate. One of
the consequences of this decision is that students in family
medicine are mostly trained in community-based hospitals, where
they do not have much contact with specialty residents. They
therefore deal with specialists who have
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26
little contact with related university departments. The
professors teaching in the residency programs of both types of
discipline therefore do not often interact with each other in joint
teaching projects. The result is that specialist physicians have a
limited understanding of the actual training received by general
practitioners, and some of them have the impression that it is
training at a discount. Clearly this attitude does not foster
healthy collaborative relationships.
I wouldnt have a clue as to where theyre getting trained, either
in psychotherapy or social work There hasnt been a single family
practitioner to come through our training program in years, not
even taking it as an elective. So, to me, thats a real problem
because I think family physicians do an extraordinary amount of
mental health care. But I would propose that theyre really
ill-trained for it. Ill go back to my first thing. I dont know if
theyre trained for it. (Director of a psychiatry program) Well,
they do thing