Are we nearing the end of primary care generalism?

It beggars belief, much less reason, that the College of Family Physicians of Canada (CFPC) would disavow itself of generalism, a concept fundamental to the professional identity of family medicine. The final report of the Outcomes of Training Project (OTP, January 2022) fooled me completely. Though it was relatively easy to see the report as a political document, it was also easy to miss a more subtle agenda. Conspiracy theories aside, the facts are what they are. The CFPC has abandoned primary care generalism. Instead, it has chosen to embark on a peremptory long-term strategy that ultimately converges with board-certified specialties. And here I thought all they needed was a little help defining generalism, assuming they wanted it. They do not. Read: Generalists in denial The trail of bountiful reasoning in the OTP final report cites a key supporting document, the Residency Training Profile (RTP), which lays out a detailed set of competencies requiring three years of formal training. Many have argued that a mandatory third year in family medicine would be superfluous. Proponents justify program extension based on increasing complexity in the science of medicine and a sense that graduates after two years are ill-prepared—both arguments that lack objective evidence. What puzzled me more, though, was the frank admission that after almost 70 years of “trying,” the CFPC has yet to come up with a distinctive philosophy for generalism in primary care. Let’s make no mistake, they’re a bunch of smart docs at the College. And yet after all this time, still no distinguishing philosophy, no clearly differentiated role? It doesn’t square. Enter the RTP, which explains everything. From what began in 1954 as an attempt to establish primary care medical practice on a concept of generalism, family medicine is now morphing into a hybrid form of specialization. Shedding their former identity, family physicians will now re-emerge as self-respecting quasi-specialists. What path is the CFPC taking? The OTP final report opens with a quote from family medicine pioneer Ian McWhinney stating, “If we [family physicians] are to fill our place, it is crucial that our commitment be unconditional; patients should feel confident that they will never be told ‘This is not my field.’” It stings a bit to see how McWhinney’s legacy is being used to justify and ennoble a succession in professional role, while abandoning the generalist orthodoxy he championed. It’s clear that the CFPC wants to have it both ways, generalist and specialist. The RTP designates eight fields of specialization leading to a Certificate of Added Competency (CAC). With passing casualness, the preamble to each specialty-oriented program assures the reader that graduates are forever “committed to the delivery of accessible, high-quality, comprehensive, and continuous front-line healthcare.” The professed values of comprehensiveness and continuity are more a proprietary trademark than they are the features of a distinct professional identity. Read: We need more privatization to save our crumbling healthcare system Such values certainly enable generalist practice, but in no way do they even begin to embrace its full meaning. The notion that CAC holders will uniformly implement these ideals across specialties is rank nonsense unless, of course, board-certified specialists are equally capable of doing so, in which case family medicine loses whatever cachet it may have had as a “unique discipline.” Only recently a CCFP(EM) grad told me frankly that she opted for specialization specifically to avoid the travails of the comprehensive/continuous model of primary care. The CFPC knows full well that within the broader context of interdisciplinary relations and medical division of labor, general practice is counter cultural. The generalist often understands optimal patient management through a lens that is not beholden to “the best scientific evidence,” and may at times choose to act in ways that constrain the primacy of specialist guidance. Such a stance engenders considerable risk, not least by reason of the fact that we live in a society raised on expectations of miracle cures and ever more sophisticated solutions. Any form of constraint, whether philosophical or methodological, would undoubtedly meet with strong resistance and ultimately undermine the standing of family medicine as a reliable partner and trustworthy provider. The CFPC has decided it does not want to challenge the cultural status quo of medical practice, nor give up a winning hand with public expectations. It’s far more prudent and pragmatic to go with the flow. More clinical specialization is better for business and there is no desire at the CFPC to be the Roger Dangerfield of medicine—so more specialization it will be. Perhaps it’s the stigma of being ‘jack of all trades, master of none’ which the CFPC feels should be upgraded to ‘jack of all trades, master of some.’ In its original version, the proverb was meant as a compliment—a jack of all trades is a master of none, but oftentimes better than a master of one—praising the generalist vs. specialist as a master of practical integrative skills. What the CFPC proposes for family medicine is uncannily similar to the strategy used by nurses who introduced extended class licenses which encroach on traditionally exclusive domains of medical practice. CACs serve the same purpose in the struggle for credibility among physician elites. It all makes perfect sense now. Why can’t the CFPC define generalism? To their credit, they make no pretense of knowing what generalism is. In effect, the concept has been reduced to a mere vestige of history. The CFPC has failed to come up with a working definition for the simple reason that they have no commitment to the idea. Maintaining a vital balance between art and science in medicine is what generalism does. If generalism survives, it won’t be thanks to the CFPC. Dr. John MacIntyre is a retired generalist now. Read: Doctors in short supply

Are we nearing the end of primary care generalism?

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