Generalists in denial

Family medicine has a big credibility problem. Some use ‘crisis’ to describe the looming predicament. The College of Family Physicians of Canada (CFPC) leadership, though, does not seem particularly concerned. Which perception is correct? According to a Chinese proverb, “If you want to know what water is, don’t ask the fish.” A lot of churn has been going on in recent years at the CFPC with multiple reports aimed at reinforcing the professional identity of family physicians. The Outcomes of Training Project final report (Jan 2022) consolidated several benchmark studies from previous years, including the Family Medicine Professional Profile, the Residency Training Profile, CanMEDS-Family Medicine, CanMEDS-Family Medicine Indigenous Health, Assessment Objective for certification in Family Medicine, Patient’s Medical Home Vision, and more. The shear bulk of material contained in these documents can have an imposing effect. As a defence of professional identity, however, their combined rationale is unpersuasive. An ever-shifting time-, place-, and technology-dependent description of ‘what we do’ does not explain ‘who we are.’ The report is pure politics, a fulsome tissue of soft or non-existent evidence backed by fiat. Family medicine apologists foist off a job description—comprehensive, continuous, community-based, etc.—that is now little more than a social meme, not a conceptual foundation for generalism. Read: Is intermittent fasting actually good for weight loss? Here’s what the evidence says Not that the issue hasn’t been given much thought. A 2018 article cited in the OTP report highlights decades of preoccupation with professional identity: “Since its establishment in 1954, the CFPC has been persistent in trying to address the challenge of defining family medicine as a unique specialty with expertise in generalism.” Buried in Recommendation #1 (1.2) the same report proposes a scholarship series, “to further develop our understanding and definition of generalist expertise . . ..” Evidently, a definitive working concept of generalism remains elusive after nearly 70 years of trying! If a generalist philosophy of care truly lies at the heart of family medicine, we need to acknowledge that the discipline can’t yet tell us who they are or what it is. If family medicine is unique in any sense, it’s uniquely undefined. Why such inertia? Why so long? While docs are adrift, patients are moving on. Support group Active Surveillance Patients International (ASPI) represents such a move. Frustrated by cross-currents of advice about prostate cancer, and driven by a personal conviction to understand choices on their own terms, the group has a mission to ask questions and search for answers they themselves consider relevant. Members are encouraged to trust their own judgment (“inner compass”) often in contradiction of treatment plans recommended by specialists in the field. In effect they have had to fill in a gap left vacant by primary care physicians. Chairman and founding member, Mark Lichty, is unequivocal. In his biographical account posted to the group’s website he states: “Both democracy and health care have something in common…their price is eternal vigilance. One of the big shifts in my medical life has been the realization that I am my primary health care provider. Yes, I have many resources around me, various physicians, the internet, support groups, books, etc. My physician is one of these resources. This is different from days of yore pre-internet, and pre support groups. In those distant days, we kowtowed to the physician who was the unquestioned authority.” By default, Lichty and the ASPI support group have become practising primary care generalists—framing the right questions and finding the right answers. In practical terms, the foremost question patients need help answering at every stage of care is not, “What’s wrong?” (diagnostics), or “What should I do?” (therapeutics), but “What should I ask?” (patients shaping their own understanding). Family medicine, by contrast, finds it difficult to shed anachronistic thinking. The past is not a reliable prototype for the future. Ask Mark Lichty and the ASPI support group. The message for family medicine advocates is unmistakably clear: adapt or go extinct. Dr. John MacIntyre is a retired generalist now and well beyond worrying about reputation.

Generalists in denial

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