Generalism is the essence of family medicine. How does specialization fit in?

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  1. Franklin Warsh

    There are two key problems that underlie the “existential crisis” in generalist family medicine/primary care, only one of which is acknowledged.

    First, medicine in Canada, particularly primary care medicine, is a set of credentials without a firm job description or functioning job market. Governments lucked out when doctors stuck to their guns on self-employment. The sad mess we call the primary care infrastructure in Canada is built on an untenable model of doctors paying for their own offices expenditures. We simply can’t expect doctors to curtail their professional goals when they’re also responsible for their own overhead. Furthermore, the attempts to jury-rig a job market – billing number restrictions, Patients First-type schemes – have ultimately proved self-defeating, especially in rural areas that need doctors devoted to the local community.

    What’s not acknowledged, however, is the deteriorating nature of general practice itself. Even taking EMRs out of the equation, how much of a family doctor’s day is now devoted to mindless and tedious bureaucratic work? “Dr. Google”-driven demands for referrals, lawyers’ letters, forms, clarification notes on already-completed forms, appeal letters for rejected disability forms, phone tag with home care providers, absentee notes in workplaces, prescription authorization forms, unreimbursed QI projects, downloading of test bookings from specialists…

    While much of this requires medical knowledge and training, none of it constitutes medicine. And combined with the growing volume pressures, time pressures, and income cuts from government, can we honestly be surprised that new doctors don’t want the job? And do we honestly think more residency is the answer?

    If, as a country, we want proper primary care, we’re going to make the job worth doing, and fund a proper infrastructure to support it. Otherwise, it doesn’t matter how many years medical graduates spend in residency…they’ll still take a pass on being generalists.

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