Generalism is the essence of family medicine. How does specialization fit in?
Ten years ago, Marie-Dominique Beaulieu described her profession as an “endangered species.” Concerned about a lack of interest in family medicine among graduating physicians, the family doctor and Université de Montréal professor surveyed educators and residents at four Canadian medical schools about their perceptions of the field. Many family medicine residents reported feeling overwhelmed by the “huge” scope of practice in primary care and said that because of this, they were attracted to the idea of developing a specific area of expertise. Beaulieu and her co-authors called this “the siren call of specialization.”
Why so ominous? It’s because family medicine has long been considered a generalist field, one in which doctors know and do a bit (or more) of everything. The signature responsibility of family doctors is comprehensive care, and the definition of comprehensive care is thought to be twofold. For one, it means the physician works in multiple settings: clinic, hospital and home. And for the other, it means the physician sees patients of all ages throughout their lives, providing preventive, curative and palliative care. When doctors who have trained in family medicine opt to specialize in a related but narrower field, two things are thought to be threatened: the availability of comprehensive care, and the essence of family medicine.
In the name of preserving this essence, the College of Family Physicians of Canada released a position statement earlier this year declaring a commitment to comprehensiveness of care as a core tenet of family medicine. Along the same line, the College’s new competency-based curriculum, Triple C, which was introduced into all Canadian residency programs beginning in 2011, highlights the importance of comprehensiveness and continuity of care.
But the College has also made room for specialization, adding a section for Communities of Practice in Family Medicine, which includes 19 areas of medicine that family doctors practise to a greater or lesser extent (often described as “special interests”), and sometimes exclusively (often described as “focused practices”). In five of these areas—elderly care, palliative care, emergency medicine, family practice anesthesia, and sport and exercise medicine—doctors can obtain a Certificate of Added Competence (CAC), signifying that they have met national standards. The College will soon begin offering CACs in addiction medicine and enhanced surgical skills.
Are these two agendas contradictory? Is specialization the foil of generalism? How much of a threat does it actually pose to comprehensive family medicine?
How many family physicians are specializing?
In the National Physician Survey of 2014, 32 percent of family physicians in Canada described themselves as “family physicians with a specialty focus.” In 2010, the number was 30.5 percent, and in 2007 it was 29.5 percent. In a survey published this past July in Canadian Family Physician, 36.6 percent of graduating family doctors reported that they intended to focus their practices.
Family doctors who hold Certificates of Added Competence are generally thought to have focused practices. They number about 4,500 out of the College of Family Physicians’ 30,000 members, or 15 percent, according to Roy Wyman, director of CACs at the College. A large majority of these are in emergency medicine.
A history of specialization
The first family medicine specialty was born in 1982, when the option to take an extra year of training in emergency medicine became available to doctors who had completed Canada’s two-year family medicine residency. This was apparently a response to a shortage of emergency physicians in the country. After that, further options for extra training began cropping up, and today most family medicine programs offer it in any number of fields: obstetrics, cancer care, and Indigenous health, to name a few. These programs are typically referred to by medical schools as “enhanced skills training.” Some are only three months long, but several last a full year, including those in the areas where a CAC is available.
“The desire to do extra training in third year has always been relatively high,” says Roy Wyman. A 2009 study found that, overall, family medicine residents and program directors thought that there should be one third-year spot for every three family medicine residents. But the reasons for this desire are hard to tease out, says Wyman. “How much is due to residents truly feeling they want to focus their practice? And how much is due to just not feeling ready after two years, the classic feeling of anybody going into any type of unsupervised profession?”
Family medicine in particular may lend itself to this kind of feeling, given the scope of practice inherent in comprehensive care. And this may become increasingly daunting as medical knowledge grows. “There are way more things to know because of the advance of technology,” says one recent family medicine graduate. “Our standard of care has gotten better, but that’s at the price of having to know more things. When people say there’s a loss of generalism, it’s not that there’s a loss of generalism. It’s that you can’t perform generalism as well as you could before.”
Especially, some people say, when you’ve only been training for two years. Canada’s family medicine residency is the shortest in the world and the College is currently studying the possibility of extending it to three years. This might be particularly useful for rural physicians, who are often called upon to cover obstetrics, emergency, palliative care, anesthesia and even surgery. The third year could be “an opportunity to continue to broaden skills,” says Sarah Newbery, a family physician in Marathon, Ont. “Extra time, but not with the goal of focusing.”
Is specialization considered more valuable than generalism?
A 2003 study out of Johns Hopkins found that a health care system with high quality “primary care, particularly family medicine, was associated with better health outcomes,” including increased life expectancy. And yet, the family medicine residents surveyed in Beaulieu’s 2008 research described a sense that their field was less important than those with more discernible areas of expertise. They talked about specialist friends saying to them, “You’re just in family medicine,” and often felt specialists were perceived as having more “legitimacy” than they did.
This may be more than a perception. For example, doing a plus-one year in emergency medicine is almost required for family doctors who want to work in urban emergency departments. “I think it’s the reality of employment and job opportunities,” says Wyman. “When you have the opportunity to hire somebody who has the extra training—and people are always looking for extra training—then that’s often the person you’re going to look for.”
The College is concerned about “credential creep,” which may leave family physicians who want to do emergency or palliative medicine feeling unqualified to do so, despite the fact that they are. That was never the intention of extra post-residency training, nor of the College’s CACs, says Wyman. Instead, he says, the idea is for family doctors with specialized training or experience to be doing more complex work in those areas, and to act as supports and consultants to other family doctors. With this emphasis on collaboration, the College is trying to prevent credential creep.
Is specialization a threat to family medicine’s generalist soul?
In 2015, Roger Ladouceur, associate scientific editor of Canadian Family Physician, challenged the CAC program, writing: “It is as though the College were dedicated to training family physicians but also to supporting the emergence of mini-specialties within its own organization.”
The College is currently studying the impact of CACs on its members’ perceptions and practices, and has put a moratorium on new CACs while it awaits the results.
It is also exploring how to better help family doctors add extra training after they’ve graduated and practised for a few years. This would mitigate the risk that physicians lose their family medicine skills when they turn to a narrower area of practice immediately after the two-year residency, says Wyman. And it would give them a chance to see what extra skills are really needed by the communities they’re practising in. As it is right now, doctors typically have to take time away from their practices as well as a pay cut if they want to do extra training. They can apply for funding, but are often expected to provide a “return of service,” meaning they promise to practise in a designated geographic area for a period of time.
Another change both Wyman and Newbery point to is increasing interest within Canada’s family medicine community in the idea of a “patient medical home.” The idea here is that rather than one doctor treating one patient, a group of individuals collaborate to provide primary care. For example, on a team consisting of family doctors with different areas of special interest, nurse practitioners, and allied health professionals, all providers would contribute to the care of their own as well as each others’ patients.
It may be that the definition of comprehensive care is changing, increasingly blending a generalist practice with special interests. Jesse Marantz, a family doctor in Winnipeg, has an office practice where he sees children, adults and geriatric patients every afternoon. In the morning, he works on a hospital psychiatric unit, providing non-psychiatric medical care to the inpatients. And one week out of every six, he works as a surgical assistant at a community hospital. “By the end of residency, I knew I didn’t want to do just office practice,” says Marantz. He finds the variety in his schedule helps his general practice. “The nuances of working with different people in different settings gives me a broader perspective than if I was to pigeon-hole myself in just one practice setting.”
This type of mix—practising comprehensive care for a population of patients in the community and providing more specific care to patients in the hospital—is perhaps the ideal marriage of generalism and specialization, says Marie-Dominique Beaulieu. “I do think that many, many family physicians enjoy the variety,” she says.
But she also thinks the importance of generalism is not yet well enough understood. The true value added by family doctors, she says, is the scope of their practice. This is their specialty. The fact that they see so many different kinds of patients on an ongoing basis builds their knowledge base and also allows them to figure out what a particular patient needs at a particular moment in time. Family medicine has been described as being “about relationships,” says Beaulieu, but this perhaps does family medicine a disservice. “It’s the scope of practice that builds the relationship,” says Beaulieu. “This is something that is profound about our identity.”