Family practice: Professional identity in transition. A case study of family medicine in Canada

Social Science & Medicine 67 (2008) 1153–1163

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Family practice: Professional identity in transition. A case study of family medicine in Canadaq Marie-Dominique Beaulieu a, *, Marc Rioux b, Guy Rocher b, Louise Samson c, Laurier Boucher a a

Family Medicine, Universite´ de Montre´al, Montre´al, Que´bec, Canada Sociology, University of Montreal, Montre´al, Que´bec, Canada c Radiology, University of Montreal, Montre´al, Que´bec, Canada b

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 20 July 2008

With increasingly fewer family physicians in many countries and students less interested in primary care careers, generalists are becoming an endangered species. This situation is a major health care resource management challenge. In a rapidly changing health care environment, family medicine is struggling for a clear identityda matter which is crucial to health system restructuring because it affects the roles and functioning of other professions in the system. The objective of our study was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian medical school faculties of medicine, using both focus groups and individual interviews. In addition to family medicine, we targeted residency programs in general psychiatry, radiology and internal medicinedthree areas that interface significantly between primary care and specialized medicine. In each faculty, respondents included the vice-dean of postgraduate studies; the director of each relevant program; educators in the program; residents in each specialty in their last year of training. Findings are centred around three major themes: (1) the definition of family medicine; (2) family medicine as an endangered species, and (3) the generation gap between young family physicians and their educators. The sustained physician–patient relationship is considered a core characteristic of family medicine that is much valued by patients and physiciansdboth generalists and specialistsdas something to be preserved in any model of collaboration to be developed. Overall, two divergent directions emerge: preserving all the professions’ traditional functions while adapting to changing contexts, or concentrating on areas of expertise and moving towards creating ‘‘specialist’’ general practitioners, in response to a rapidly expanding scope of practice, and to the high value attributed to specialization by society and the professional system. Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Family medicine Professional identity Sociology of professions Canada Primary care General practitioners

Introduction

q The authors wish to acknowledge the contribution of Donna Riley, translator and editor, in the preparation of this manuscript for publication. * Corresponding author. Centre de recherche du CHUM, Pavillon L.-C Simard, 8e stage 1560, Montre´al, Que´bec, Canada H2L 4M1. Tel.: þ1 514 890 8000; fax: þ1 514 412 7579. E-mail addresses: [email protected] (M.-D. Beaulieu), [email protected] (M. Rioux), [email protected] (G. Rocher), [email protected] (L. Samson). 0277-9536/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2008.06.019

What is a family physician/general practitioner?1 Paradoxically, in an era when the primary care sector is at the 1 We consider the expressions ‘‘family physician’’ and ‘‘general practitioner’’ as interchangeable in describing the physician who can deal with a variety of problems in a population of patients regardless of age and gender, in contrast with the term ‘‘primary care physician’’ that includes, in the United States, specialists of certain disciplines such as pediatrics, OB/GYN and internal medicine.

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heart of most industrialized countries’ efforts to reform health care, health care managers, decision-makers, patients and professionals are struggling with this question more than ever. The proportion of general practitioners is not increasing as much as the proportion of specialists in most OECD countries (Organisation for Economic Cooperation and Development, 2007). Students’ diminishing interest in primary care careers has been documented in the United Kingdom, Canada and the United States (Bowler & Jackson, 2002; Rosser, 2002; Sox, 2003). Due to factors such as career choices and reduced working hours, some OECD countries are experiencing a relative shortage of primary care physicians, particularly Canada, Australia and the United States (Simoens & Hurst, 2006). A growing proportion of general practitioners are restricting their practice, which diminishes access to primary care providers, particularly in rural and remote regions. For example, in Canada 20% of family physicians polled in the 2007 National Physician Survey planned to limit their scope of practice in the coming year (National Physician Survey, 2007). This phenomenon is also emerging in France (Levasseur & Schweyer, 2005) and Belgium (Dilie`ge, 2004). Trends towards increased specialization, when some OECD countries are promoting a primary care-driven health care system, have become a major challenge of health care resource management (Simoens & Hurst, 2006). Some argue family physicians’ traditional large scope of practice is unrealistic in an era when knowledge is growing exponentially. One response to this challenge, the development of the so-called ‘‘specialized family physician,’’ seems particularly attractive not only to a new generation of family physicians, but also to some health care managers and administrators (Green & Fryer, 2002; Rosser, 2002; Soulier, Grenier, & Lewkowicz, 2006). Indeed, in the United Kingdom, proposals to foster the development of careers as specialist general practitioners have been put forward by the National Health System and the Royal College of General Practitioners (Department of Health & RCGP, 2002). In response to the perceived decreased interest in general practice and the pressure on general practitioners to specialize, pleas to define the discipline better have been made in many countries by family physicians themselves (Graham et al., 2002; Kamien, 2002; Olesen, Dickinson, & Hjortdahl, 2000; Wun, 2002). Many general practice organizations have revisited their definition of the discipline (College of Family Physicians of Canada, 2004; Future of Family Medicine Project Leadership Committee, 2004; Wonca Europe, 2002). However, these new definitions have not achieved unanimous acceptance and many tensions within the discipline persist (Bailey, 2007; Green & Fryer, 2002; Heath & Evans, 2000). It is widely recognized that developments in primary care call for new, more comprehensive models of professional practice in which, to ensure optimal use of available expertise, professional roles must adapt. Nurses, pharmacists and other health professionals must assume more responsibilities, taking on certain roles that have traditionally been the domain of the family physician (Romanow, 2002; Tyrell & Dauphinee, 1999). Boundaries between professional jurisdictions are thus subject to continued renegotiation. In a rapidly changing health care environment,

family medicine is struggling for a clear identity (Green & Fryer, 2002; Stein, 2006; Stevens, 2001). The question of professional identity is not insignificant. Professionals need a clear sense of their profession’s identity and area of expertise to function effectively (Abbott, 1988). This is crucial to successful system restructuring, because how family physicians define their roles will have a real impact on the roles and functioning of other professionals in the system. To date, this question has not received the attention it deserves and there has been little empirical research into family physicians’ representations of their roles in the health care system. In the United States, seven national family medicine organizations launched, in 2002, the Future of Family Medicine Project. Interviews and focus groups were conducted with family medicine trainees and practitioners, as well as specialist physicians and consumers, to explore the core values of family medicine in the United States (Graham, Bagley, Kilo, Spann, & Bogdewic, 2004). The results highlighted that neither the general public nor the professionals had a clear understanding of what family medicine represents. There was significant variance in practice scope among family physicians. Making family medicine an attractive career option was perceived as a challenge. In France, a qualitative study in which 23 general practitioners were interviewed revealed that many questioned the social and intellectual value of their profession in a health care system that highly values technology and specialization (Soulier et al., 2006). In the United Kingdom, Jones and Green (2006) reported shifting discourses of the representations of 20 early career general practitioners, characterized by what the authors called a ‘‘new general practice’’ that explicitly rejects many traditional values, such as the vocational aspect of the discipline. Contrary to many other studies, the authors reported the expression of a high degree of job satisfaction in their respondents. We report the results of a study whose objective was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian faculties of medicine. We targeted this population because, in health, the educational system plays an important role in developing professional identity (Abbott, 1988; Bucher & Stelling, 1977; Freidson, 2001; Shapiro, 1978), and the apprenticeship model used in medical training significantly affects how physicians internalize professional roles (Bucher & Stelling, 1977; Shapiro, 1978). Background Primary care in Canada In 1984 the Canada Health Act set the ground rules for what was to become the Canadian health care system. The Act guarantees to Canadians universal and free access to ‘‘medically required’’ services provided by physicians and hospital services. Most primary care services are provided by family physicians who operate as independent practitioners and bill directly to the state authority under a fee-for-service system. About 40% of these are solo practitioners. Only 6% of family practices employ other health

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professionals, mostly nurses. About 20% of family physicians work in primary care centres on a salary or contract basis, and generally within multi-disciplinary teams. The ratio of family physicians to total population is among the lowest in the OECD countries, at 1 per 1000 inhabitants. In the Canadian system, family physicians provide almost 50% of care in community hospitals, and thus are not devoted exclusively to the primary care sector (Canadian Institute for Health Information, 2003). This further inhibits access to primary care and also affects the provision of specialized services, rendering the flow between primary and secondary care suboptimal. Primary care does not exercise any gatekeeping role on access to specialist care. All Canadian provinces, responsible for the organization of care in their territory, have launched important primary care renewal initiatives in the past decade. Although details vary between provinces, all aim at: (1) integrating other health professionalsdmostly nursesdinto family medicine practices to improve access and continuity of care through a redistribution of responsibilities; (2) integrating family medicine practices into regional governance structures responsible for other primary care services, using contracts based on objectives related to numbers of registered patients and accessibility; and (3) improving the flow between primary and secondary care. Although medical practice falls under provincial jurisdiction, the accreditation of medical training programs is done nationally. The exams leading to practice permits are also national exams. Competencies and training activities are defined at the national level by two colleges: the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. Trainees at the postgraduate level are called ‘‘residents’’. The family medicine residency program takes two years and specialty programs take five. Family medicine residents are attached to a family medicine teaching practice throughout their residency. Since 1988, all family physicians must have completed a residency in family medicine. Currently there are 17 schools of medicine distributed across Canada’s 10 provinces and its territories. While each has its own individuality, in terms of the fields of expertise it chooses to develop, all must offer programs that respect national standards. Educators and residents from across Canada participate in their colleges’ national committees, providing opportunities for them to share their visions of their discipline, even if the realities of practice vary across the country. Conceptual framework To explore family physicians’ perceptions regarding the role, image and position of their profession, we borrowed from the systemic framework developed for the analysis of professions by Andrew Abbott (1988), which delineates the bases of professional identity and adds to Eliot Freidson’s (1970, 2001) seminal work on professions. Abbott’s work on the professional system also has much in common with the systemic theory of the legal profession developed by Niklas Luhmann (2004). Luhmann asserted that a profession is a social system that is both self-enclosed, defining and retaining its identity by maintaining boundaries with

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its environment, and at the same time open, insofar as it is sensitive to exterior environmental influences it senses along those boundaries (which Luhmann calls ‘‘irritants’’). To preserve its autonomy, identity and internal equilibrium, the professional system absorbs elements coming from outside in its own way, in accordance with its professional logic and the requirements of its own tasks. This is how evolution and change occur within a profession perceived as a system dynamically related to a larger system and other systems. Using systemic approaches to the study of professions allows us to extend beyond, but still include, classic definitions of professions based on specific traits that set them apart from all other occupations (Cogan, 1953), or the analysis of the medical professions in terms of standards and values (Hall, 1948, 1949), or interactionist (Coombs, 1978; Hughes, 1961) and functionalist (Parsons, 1951) approaches, from which Freidson was already distancing himself (Freidson, 1970). Abbott’s analysis of the professional debate on competence boundaries in medical professions follows precisely the same theoretical direction as Luhmann, without necessarily claiming to represent it. According to Abbott, a discipline’s ability to defend its jurisdiction depends on its capacity to establish its role. It is through the professional tasks carried out by its members that a profession can establish its identity, legitimacy and jurisdiction in contrast with other professions with which it is interdependent. These tasks have three bases: objective foundations, subjective foundations and a system of specific codified or academicized knowledge.  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 disease) or a cultural fact (such as aesthetics or spirituality).  The subjective foundations of professional tasks, grounded in practice, are the most important bases of the profession. Abbott categorizes subjective bases according to the three major phases in any professional work: the diagnosis of problems, their treatment, and the process of inference that leads to a diagnosis and associates it with a treatment.  A system of specific, codified or academicized knowledge gives legitimacy to professional work by clarifying its foundations and linking it to society’s fundamental values, such as rationality, logic and science. It is through such knowledge that the efficacy of treatments can be demonstrated. This knowledge 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. Purpose and objectives of the study For the purposes of our study, we turned to Canada’s medical schools. We wanted to find out how two different sub-groups of the professiondleaders who occupy positions in academic medicine and future family physicians reaching the end of their trainingdperceive the role of family medicine. We also wanted to explore their ideas

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about issues such as scope of practice, pressures towards specialization, relationships with patients, societal expectations and other sources of professional tension. To complement these observations, and to recognize this systemic interdependence of the profession of family medicine, we chose to interview representatives of three specialties that have important interactions with family medicine. Methodology Design and study population This is a case study based on a multiple-case design (Yin, 1994), each ‘‘case’’ being a medical school. There are 17 medical schools distributed in Canada’s five regions. Some are strongly oriented towards community practice and primary care, while others are more oriented towards specialized care and research. We wanted to contrast the cases on these two characteristics, since data suggest that medical schools’ missions may be associated with the careers chosen by their graduates (Bland, Meurer, & Maldonado, 1995; Whitcomb, Cullen, Hart, Lishner, & Rosenblatt, 1992). Hence, four cases were chosen (each from a different region), two having a primary care orientation in their mission statement and two considered as specialty-oriented. The residency programs we targeted were family medicine, general psychiatry, radiology and internal medicine. These three specialties were selected because they play an important role in the interface between primary care and specialized medicine. For each case, four categories of respondents were approached in order to reconstitute the ‘‘pedagogical’’ chain: 1. the vice-dean of postgraduate studies (individual interview); 2. the director of each relevant program (individual interview); 3. educators in the program (focus groups or individual interviews); 4. residents in each specialty in their last year of training (focus groups or individual interviews). Study and interview processes Respondents were selected as follows. First, the vicedeans of the chosen medical schools were approached to obtain their support for the project. Then the directors of the residency programs selected for the study were invited to participate and, with their assistance, eligible residents and professors were also invited. Our aim was to meet with four educators per program, five or six residents in family medicine and up to four residents in specialty programs. In fact, in certain faculties, the number of graduates in specialty programs is quite small. Also, the residents had to be available when the research team was there. Interview methods were chosen based on the characteristics of respondents. We did not want to conduct group interviews of people with different positions or from different professions. Thus, interviews with vice-deans and program

directors were all planned as individual meetings. On the other hand, we offered the possibility of meeting with educators and residents of a given specialty either in groups or individually to accommodate schedules and the numbers of participants. Focus groups promote interactions and debate among participants, giving rise to rich discussions and a better understanding of the opinions expressed (Krueger, 1994). The interview guides used in individual and group interviews were the same, and the same dimensions were explored with each category of respondent. The interview began with a general question on their vision of the role of physicians in the health system. After this, we asked how they saw the roles of family physicians, medical specialists and other professionals, particularly nurses; what distinguished the family physician’s role from those of other professionals (i.e., what was specific to them, their ‘‘core business’’ or expertise); how they envisioned the start of their career (for residents); their perception of family medicine’s place in the Canadian health system; and what they saw as the key issues facing family medicine. Interviews were conducted by three of the researchers (mainly MDB and LB, and LS for some). Group interviews lasted 90 min and individual interviews, between 45 and 60 min. Analyses The interviews were transcribed for analysis. The researchers participated in the analysis, bringing the perspectives of their respective disciplines (sociology, social work, family medicine and specialized medicine). First, they immersed themselves individually in the data by reading all interview transcripts and consulting notes from each interview. They then put their interpretations together and compared their lists of identified themes and sub-themes. The transcripts were coded according to these themes using a simple word processing software. Because we did not use two different interview methods with the intention of triangulation, we did not systematically compare themes according to whether they emerged from individual interviews or from groups. This project was accepted by the ethics committee of each participating institution, including the Research Ethics Committee of the CHUM (Centre hospitalier de l’Universite´ de Montre´al) Research Centre, where the principal investigator is affiliated. We found no differences in ideas expressed by respondents from universities with and without a stated community-based orientation and therefore did not retain this parameter in presenting our findings. Findings Participation in the study was broad-based and comprehensive. All the vice-deans of graduate studies and all the program directors (with the exception of two in radiology) participated. Table 1 summarizes the characteristics of the respondents and Table 2 describes the distribution of the respondents according to the type of interviews. Our findings are reported here according to three major themes: (1) what is a family physician?; (2) family

M.-D. Beaulieu et al. / Social Science & Medicine 67 (2008) 1153–1163 Table 1 Characteristics of the respondents Category

Mean age

Gender

Total

Male

Female

N (%)

Residents Family medicine Specialty Sub-total residents

26.3 30.1

12 9 21

17 9 26

29 (61.7) 18 (39.3) 47 (100)

Educators Family medicine Specialty Sub-total educators

50.2 55.1

9 22 31

11 3 14

20 (44.4) 25 (55.6) 45 (100)

52

40

92

Total

medicine as an endangered species; and (3) the generation gap between young family physicians and their educators. We conclude with the views of specialists. What is a family physician? The following interview excerpt provides 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 patient’s age (pediatric, adult or geriatric) or the illness. This requires a wide range of skills because various approaches are required.The role of a family physician includes ensuring that the patient has all he may need in terms of treatment. It’s like explaining everything that’s going on.being able to educate the patient.’’ (Resident in family medicine) Generally speaking, a large scope of practice and the continuing relationship with the patient formed the core of respondents’ definitions of family medicine. Within these core characteristics, three sub-themes emerged, presented below. A large scope of practice, but what does it mean? While the view that family physicians must provide a large scope of practice is widely shared, two different perspectives on ‘‘scope of practice’’ were proposed. Table 2 Distribution of the respondents according to the type of interview Category

N interviews

N respondents

Individual interviews Associate deans Program directors Educators Residents Sub-total individual interviews

4 13 6 4 27

4 13 6 4 27

Group interviewsa Educators Residents Sub-total group interviews

6 8 14

22 43 65

Total

41

92

a

All the interviews with family medicine residents and educators were group interviews.

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Some family physicians and most specialists interviewed defined family medicine’s scope of practice on the basis of functions, two of whichdfirst response to any patient’s enquiry, and the coordination and integration of the care experiencedthey considered to be the discipline’s foundation and core. ‘‘For me, family physicians have two fundamental roles: first, to be able to deal with any medical complaint as it is presenteddit may mean that the solution is to refer the patient to another professional; second, to be able to orchestrate the care of their patients through the system that is getting more and more complex.’’ (Family medicine program director) Other respondents defined scope of practice based on 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 family physician’s role, i.e., to the family physician’s responsibilitydalone or in a groupdto respond to all primary care needs of his or her clientele and, in small communities, to the needs of the community as a whole. This was a vision entertained only by family physician educators. Respondents used the term ‘‘fullservice 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) The siren call of specialization Although the majority of respondents identified a wide scope of practice as fundamental to family medicine (effectively agreeing with the dominant professional view), their responses also clearly revealed an enduring conflict between scope of practice and expertise. This conflict, which captures the tension between family medicine’s 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, it’s 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, it’s expertise as well. It’s just to be feeling that I’m able to do a good job at everything. And I honestly don’t feel that I can stay on top of it all, there’s something that has to be cut.’’ (Resident in family medicine) This questioning leads future family physicians to conclude that a specialist’s legitimacy will be more easily won than their own, even if they believe their functions

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as first respondent, coordinator and integrator are critical to the health care system. ‘‘I had specialist friends who said, ‘You’re 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 family physiciansdresidents or educatorsdthe recognition accorded to specialization is an irritant and a constant source of concern. Some mention the extent of current knowledge, the way health care is organized and their life objectives and simply conclude it is impossible to sustain such a wide scope of practice. Even those who say they are comfortable with a non-expert status 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.Because doing everything just seems too much.’’ (Resident in family medicine)

Fortunately, there is always the relationship with the patient. Unable to define themselves in terms of a specific expertise, as professions traditionally do, family physicians fall back on what is generally considered a basic characteristic of their profession: their relationships with their patients. For all our family medicine respondents, both residents and professors, this serves as an anchor, their raison d’eˆtre. ‘‘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 that’s part of why you choose family medicine, as opposed to people who choose gynecology or surgery.We love to be near people and then seeing tangible small-scale results. There’s a relationship, a bond, and that’s 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 attraction, it can also be perceived 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 you’re worried about picking on patients you may not like.’’ (Resident in family medicine) ‘‘A major obstacle for me, I think, is going to be the balance of family and work. I keep hearing over and over again from patients, ‘What, the family doctor doesn’t do house calls? What, the family doctor doesn’t do after-hours work?’ What, we can’t reach the family doctor on the weekend? I hear this and in my own head I’m thinking, I don’t know if I want to be reached on weekends.’’ (Resident in family medicine).

Family medicine as an ‘‘endangered species’’ All the physician educators interviewed, generalists or specialists, spoke of a ‘‘crisis’’ or of ‘‘danger.’’ Several family medicine educators referred to the profession as an ‘‘endangered species.’’ ‘‘My fear is obviously that we won’t have family medicine in ten years, that it will be all specialists or GPspecialists. 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 who’s probably going to make more and more use of the system over the next ten years.’’ (Family medicine educator) Indeed, many family educator respondents believe specialization among family physicians represents a real danger to the profession’s survival, because the health care system has a vital need for an integration function which, up to now, they have fulfilled. If they disappear, someone else will have to take their place. Others observed that the situation plays out differently in urban areas than in rural communities. ‘‘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 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.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.So I guess I see an evolution in two streams: one is increasingly focused and the other is, in a sense, increasingly broad.’’ (Family medicine program director) Others believe family physicians are condemned to an impossible practice, noting how little the profession is valued in the health care system and how great the expectations are. ‘‘It’s a very high level of responsibility to feel that you are responsible for all aspects of your patient’s health and that you will be held responsible for it. So when your patient shows up in emergency with an MI [myocardial infarction] and it’s deemed to be because her LDL wasn’t 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 it’s not appropriate to shoulder that kind of responsibility, and they don’t want to.’’ (Family medicine program director) Finally, many respondents identified important changes in the external environment that have created an upheaval in the system that is forcing the profession of family medicine to reconsider its functions. They described a paradox in the form of a domino effect: specialists are leaving certain specialty areas vacant, retreating into

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overspecialization, while family physicians are abandoning primary care and assuming more and more of the responsibilities that have traditionally been the domain of ‘‘specialists’’. ‘‘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). Many family medicine educators were of the opinion that the only way out of the current crisis facing the profession is to develop new models of practice that include a significant investment in interdisciplinary practice. They saw the different primary care reform initiatives as opportunities. ‘‘I think we need to move more into a different kind of public care delivery: group practice. (.) I don’t think it’s only family medicine. Some of our program director colleagues in the specialties know it’s true, that their graduates are making narrower and narrower choices. So, either we’re going to accept that competence in family medicine as we know it will no longer exist, or we need to get behind the reform movement. And I think that if we can offer the exposure and models in training, we have an opportunity to influence what the future looks like.’’ (Family medicine educator)

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‘‘I think there’s 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 you’re not living up to expectations if you don’t practice in some other area of medicine like palliative care, emergency or obstetrics or that sort of thing.’’ (Resident in family medicine) Professors also note this generation gap. They speak of a deep commitment to their discipline. Several seem to be watching, powerlessly, as their graduates lose interest in the model of the ‘‘complete’’ family physician. They speak of this situation with regret and sometimes bitterness and perceive it as a conflict of values. ‘‘One of the reasons I’m 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 we’re spreading out their duties over a larger group of people, both specialists and other health professionals. I think it’s 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 that’s a challenge too, to teach people who do not share your vision.’’ (Family medicine educator) The specialist’s perspective

The generation gap Another theme emerging from the interviews was the gulf between young physicians who embrace the added dimensions of the profession and physician educators who have difficulty letting go of the traditional view. While family medicine educators encourage students to find a balance between their professional and personal lives, several residents perceive this as ‘‘doubletalk.’’ They feel judged by their elders and professors and sometimes have the impression they disappoint them when they restrict their practice. Generally speaking, and in contrast to their professors, residents do not feel there is a ‘‘crisis’’ in family medicine. Some feel guilty, or at least uneasy and torn between a sense of responsibility to meet a societal need and fulfil the discipline’s vision of itself, and a sense that it is impossible to do it all, to incarnate the entire discipline in their individual practices. ‘‘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 I’m doing next year and I say that I’m going to do OB and palliative. I feel they are disappointed if I say, ‘Oh, I’m going to work in a clinic or do some walk-in shifts’.Heaven forbid walk-in! That’s sort of the subtle pressure: ‘Oh, that’s nice.’.’’ (Resident in family medicine)

The specialist’s notion of family medicine corresponds essentially to that of family physicians, including doubts about whether it is actually possible to fulfil the role in practice. Most of the specialist physicians interviewed, both residents and professors, feel it would be impossible to provide the public with medical services without family physicians. The family physician’s expertise in evaluating and managing a broad variety of cases is widely recognized. The functionsdaccessibility to, continuity of and coordination of caredare considered vital. Specialists also acknowledge the unique relationship between family physician and patient that is built up over time. ‘‘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.The family doctor controls the overall care of the patient. In other words, he may receive expert advice from a consultant or whatever, but I’m talking about the ‘ownership’ of that patient, the primary care provider, the person who coordinates all the health care provided to an individual: it’s the family doctor.’’ (Internal medicine program director) ‘‘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

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that.It’s incredible! In fact, the scope of medical knowledge has become enormous. And we are asking people to master it all.’’ (Vice-Dean) However, other specialists see things differently. ‘‘I don’t think everybody should be doing everything. So I don’t think the physician should be delivering babies, seeing children, looking after an infarctus, going to assist surgery.I think that family practice trainees should gear their practice, to a large extent, around their interests.’’ (Specialist in internal medicine) ‘‘I see family medicine as quite beleaguered.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 aren’t available, so family physicians are burdened with having to do too much because they don’t have access to the many levels of specialties.’’ (Vice-Dean) The specialists we interviewed see themselves as observers of the identity crisis in family medicine. While affected by its repercussions, they do not feel implicated in the search for solutions. ‘‘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 don’t quite know how we are going to get out of this mess.’’ (Vice-Dean) Discussion Our data confirm that the profession of family medicine in Canada is going through an evolution and a self-examination that touches specifically upon the systemic boundaries of its identity: the ‘‘irritants’’ of others’ perceptions; the practices of specialists; the generation gap; training that occurs particularly in the university hospital setting (with its technologies and accent on specialization); and the development of knowledge. We believe Luhmann’s (2004) theory based on the legal profession, to which we alluded earlier, applies well to the practice of family medicine. It follows the same lines as Abbott and Freidson, and provides a more developed theoretical foundation. How can Abbott’s systemic theory of professions help us understand the nature of this identity crisis and its implications for decision-makers and educators? Changes in the objective foundations of family medicine The changes in governance systems that accompanied many primary care reform initiatives and the emphasis on interprofessional collaboration as a solution to the shortage of human health care resources have been identified by many of our respondents as important external drivers that are changing the objective foundations of health care professions in Canada. This accords with

observations reported in previous surveys of Canadian family physicians (Cohen, Ferrier, Woodward, & Brown, 2001; Savard, Gaucher, Rodrigue, Dube´, & Villeneuve, 2005). The interviews also reveal that family physicians perceive specialization to be strongly valued in society, despite the importance attributed to values of humanism and responsiveness in society’s official discourse on the health care systemdhence the need to defend and reaffirm their legitimacy. Changes in the subjective foundations: what is the unique expertise of family physicians? Our data confirm that the profession of family medicine in Canada is reflecting on the nature of its expertise. The two approaches to defining family medicine’s scope of practice that emerged from our respondents reveal the fundamental tension between those who define scope of practice according to expertise and the capacity to manage problems in almost all clinical settingsdfrom obstetrical care to emergency care and palliative care, ‘‘the full-service family physician’’dand those who consider that the expertise of family physicians lies in their capacity to coordinate and integrate complex health problems. We observed that family physicians educators supporting the former definition consistently appeared more worried about the survival of the discipline than did those who proposed the latter. It is also this latter definition that the specialists we interviewed acknowledged as being unique to family medicine. However, while our family physicians respondents are proud of their profession, they worry its traditional subjective foundationsdexpertise in the management of routine and poorly differentiated problems as well as chronic conditions (Wonca Europe, 2002)dare being seriously undermined by knowledge and technological developments. The testimony of the family medicine educator who feels judged for his failure to have reached the 2.0 mmol/l prescribed LDL level and the 0.07 HBAC1 target when one of his diabetic patients arrived at the emergency room with an acute myocardial infarction is particularly telling of the pressure exerted by the culture of evidence-based medicine on the notion of expert knowledge and expertise, and how this culture challenges family medicine in the professional system. This theme was expressed consistently in all the focus groups with family medicine trainees and by some of the specialist educators, who questioned family physicians’ capacity to deal adequately with the complete array of complex health care problems. Indeed, in the primary care literature, there is now a significant body of research comparing the effectiveness of treatment by general practitioners with treatment by medical specialists (Harrold, Field, & Gurwitz, 1999) and other professionalsdin particular, nurse practitioners (Horrocks, Anderson, & Salibury, 2002)dthat suggests approaches used by general practitioners are equally or less effective. The apparent ‘‘generation gap’’ revealed in the interviews is another expression of tension within the profession. On one hand is the desire, expressed predominantly by family medicine educators in our study, to preserve all the profession’s traditional characteristics and functions, while trying to adapt to new challenges posed by the

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evolution of the external environment and of the scope of practice of other professions. On the other hand, in response to the challenge of practising high-level family medicine while maintaining a balance between personal and professional aspirations, there is the tendency to develop what is sometimes called a ‘‘specialized family physician’’ or a family physician with special interest, a response that seems particularly attractive to the new generation of family physicians. This disconnection between the aspirations and values of future family physicians and those of their educators was noted by investigators in similar studies in France and Belgium (Beaulieu et al., 2006; Dilie`ge, 2004; Levasseur & Schweyer, 2005) and England (Rowsell, Morgan, & Sarangi, 1995). Neither this phenomenon nor its impact on the trainee–trainer relationship has been much explored. Does this reflect a true cohort effect or shifts of perspective across different stages in a career? The discourse of our family physician residents parallels those reported by Jones and Green (2006), who describe the emergence of a new concept of general practice among early career general practitioners in the United Kingdom, a ‘‘new general practice’’ in which clinicians can focus on areas of special interest and work in ‘‘multi-professional practices.’’ This apparent contradiction of trying to preserve a profession’s traditional roles while adapting to the rest of the professional system and the external environment fits with Luhmann’s (2004) and Abbott’s (1988) representations of professional systems: i.e., to carry out the tasks that identify the profession, and to deal with the ‘‘irritants’’ that incite it to evolve by adapting to proposals, requirements and suggestions from the cultural, technological, and administrative professional environment, a professional system is in constant tension between maintaining a certain status quo and the need to change. Academic, codified knowledge specific to family medicine: can one be an expert in generalism? Hitherto, the culture of evidence-based medicine has given rise to a somewhat reductionist view of expert knowledge, a view not called into question by our respondents, that contributes to the impression that family physicians are faced with an impossible mission. Indeed, reflecting on our results, we suggest that the real nature of ‘‘expert knowledge’’ in the professional system merits questioning. Can one be a specialist in generalism? Is ‘‘expert knowledge’’ to be defined as highly specialized content expertisedwhich, as Freidson (2001) says, is always amenable to ‘‘routinization’’dor as an expertise recognized for the application of discretionary judgment to each unique and complex situation? Is the sub-specialists’ privileged position in the medical professional system due mainly to their mastery of a large body of highly specialized knowledge or to their ability to apply this knowledge to situations that are rare and therefore complex? Taking a systemic view of the professional system, we propose that to abandon a scope of practice understood as the ability to manage and coordinate all of an individual’s health problems is to test the very foundations of family medicine and to weaken its position in health care systems,

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where the capacity to manage complex problems will become a highly valued currency. It could be argued that a wide scope of practice continues to be the profession’s fundamental characteristic, much more than the relationship with the patient, which many other professions can also claim. Like Freeman, Olesen, and Hjortdahl (2003), we think this intimate knowledge of the patient’s condition, acquired by the family physician over the years, results from the scope of practicedthe generalist aspect of the practice. It is precisely because of this generalized and comprehensive approach that the patient consults with the family physician on an ongoing basis and a relationship of trust develops. The family physician’s scope of practice precedes, explains and creates continuity, integration and trust. Without this scope of practice, the chain is broken. Strengths and limitations of the study Despite being limited to four medical disciplines, to our knowledge this is the first study to have collected the views of such a large sample of physicians on the professional identity of the family physician. It joins an international corpus of studies from France (Soulier et al., 2006), Belgium (Dilie`ge, 2004) and the United Kingdom (Jones & Green, 2006; Rowsell et al., 1995). These studies, carried out in different contexts, demonstrate the universal nature of these issues. On the other hand, our study differentiates itself from most others, in that we interviewed both seasoned and early career physicians and not only family physicians. Given the national accreditation process for training programs in Canada, and the similarities in the themes evoked by our respondents who were selected to represent the different Canadian regions and different missions, we are confident our data are representative of the situation in academic settings in Canada. Beyond the limitations inherent in our choices of professional disciplines to contrast with family medicine, there were also limitations imposed by our decision to restrict our sample to respondents involved in the teaching of their profession and their trainees. This decision arose from our recognition of the educational system’s undeniable influence on the professional system. Clearly, we cannot infer that our results reflect the views of Canadian physicians who evolve outside the academic setting. Finally, we must ask ourselves what impact the specificities of the Canadian health care system might have on our observations. The fact that many of the tensions we report have been reported in studies conducted in the American (Sandy & Schroeder, 2003), British (Marshall, Mannion, Nelson, & Davies, 2003), French (Levasseur & Schweyer, 2005) and Belgian (Dilie`ge, 2004) systems confirms that many of our observations have a resonance in Western health care systems. However, we think the issue of expertise is particularly critical in Canada, wheredas in Australiadhospital practice and the capacity to master skills traditionally reserved to specialists are included in the family physician’s scope of practice in remote areas. European family physicians in countries such as France or Belgium, where general practitioners still work on their own in fee-for-service solo or small group practices, have lamented more on the burden imposed by ensuring accessibility and availability to

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an increasingly demanding clientele than on the challenge posed by the increasing demand on the family physician’ expertise (Dilie`ge, 2004; Feron et al., 2003; Levasseur & Schweyer, 2005). The fact that our respondentsdlike most of Canadian family physiciansdare in group practices explains, we think, why ensuring continuity of care was not perceived as a burden, as it has been by some European family physicians. Finally, we believe the importance given to professional collaboration in new organization models being implemented across Canada, along with certain legislative changes, contributes to increase the perception among our respondents, both family physicians and specialists, that family medicine is in state of ‘‘crisis’’. Conclusion In summary, we observe that, strictly in terms of interprofessional relations, general practice in Canada is in a difficult position, interfacing with several health professions. This central role is also a vulnerable position, since it is subject to the influence of all the subjective and objective changes that define the other professions and set their boundaries. While there are multiple tensions within the profession (in particular, among young physicians who seek to balance quality of life with the demands of accessibility and continuity), the conflict between two views of the family physician’s expertise seems to represent the true Gordian knot of this identity crisis. The tendency to develop what is sometimes called a ‘‘specialized family physician’’ constitutes one response to these emerging challenges, one that seems particularly attractive not only to a new generation of family physicians but also to some specialists. We believe the solution lies in reaching a new understanding of the scope of practice and the relationship of trust between the family physician and the patient. Sharing the patient relationship with other professionals in collaborative practice models may be the most effective strategy for preserving the fundamental uniqueness of the profession of general practitionerdthe scope of practice, the comprehensive view of a situation, and the privileged point of view for ensuring continuous and integrated care.

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