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COLLABORATION BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS

The Gulf Between Preferred and Actual Practice

Study on the perceptions of medical residents and their educators


of the roles to be assumed by future physicians in collaborative practice
and their evaluation of future physicians preparedness for these roles

Marie-Dominique Beaulieu, M.D., FCFPC, Professor


Doctor Sadok Besrour Chair in Family Medicine
Department of Family Medicine, Faculty of Medicine, CHUM Research Centre,
University of Montreal
Louise Samson, M.D., FRCPC, Professor
Department of Radiology, Radiation Oncology and Nuclear Medicine
Faculty of Medicine and Centre Hospitalier de lUniversit de Montral (CHUM), University of
Montreal
Guy Rocher, Ph.D., Professor
Department of Sociology and Public Law Research Centre
University of Montreal
Marc Rioux, doctoral candidate
Public Law Research Centre
University of Montreal
Laurier Boucher, professional social worker, MSW, Research Associate
Doctor Sadok Besrour Chair in Family Medicine

Project funded by the Royal College of Physicians and Surgeons of Canada and
and the Doctor Sadok Besrour Chair in Family Medicine

This research has received funding from the Royal College of Physicians and Surgeons of
Canada as well as the Doctor Sadok Besrour Chair in Family Medicine of the University of
Montreal. The project was approved by the Research Ethics Committee of the Centre hospitalier
universitaire de Montral (CHUM) Research Centre.
ISBN: 2-9807566-5-2
Cite: Beaulieu M.-D., Samson L., Rocher G., Rioux M., Boucher L. Collaboration Between
Family Physicians and Medical Specialists, The Gulf Between Preferred and Actual Practice.
Doctor Sadok Besrour Chair in Family Medicine Montral, 2005. 57 pages.

TABLE OF CONTENTS

FORWARD AND ACKNOWLEDGEMENTS


1. BACKGROUND, APPROACH, RESEARCH QUESTIONS
Everyone wants to head in the same direction, but where are we actually going?

I
1

1.1 We have a consensus: A new medical practice will play a key role in current reforms

1.2 A growing gulf between the preferred vision and actual practice

1.3 The professional system: A useful tool provides a fresh look at professional
collaboration in the health care system

1.4 Training: Where professional identity is formed

Objectives and method

2. FINDINGS
Training, practices and career choices that do not always follow the general consensus
or the official view

11

2.1 So what exactly is a family physician?

11

2.2 Collaborate? Sure, but who will do what?

17

2.3 Collaboration can be learned! ... Really?

23

2.4 Summary

27

3. OPTIONS
Systemic problems require system-wide solutions

30

3.1 Respondents proposals

30

3.2 Our proposals

35
42
47

4. CONCLUSION
APPENDICES
TABLE 1 Summary of Discussions on the Nature of Professional Collaboration and the
Issues It Raises
TABLE 2 Mail Survey Results, by Residency Program
REFERENCES

48
50

FOREWARD AND ACKNOWLEDGEMENTS


First and foremost, I would like to take this opportunity to express my sincere appreciation to
everyone who has helped make this report possible.
My thoughts turn first to all the participants, the residents as well as their professors, who
accepted to meet with us and answer our questions despite their already overburdened schedules.
Unfortunately I cannot mention them by name, since of course their anonymity must be
maintained as a condition for carrying out the study.
I am also thinking of all those who made it possible to conduct our interviews: the administrative
assistants working in various programs of study and the offices of graduate studies. To all of
these individuals, I extend my sincere appreciation.
I also want to thank the members of the Section of Residents of the College of Family Physicians
of Canada who shared with me their perceptions of the issues when the study was still at a
preliminary stage, and who helped to organize some of the focus groups.
To my research collaborators who helped me develop the interview protocol and conduct the
interviews and who read the interview transcripts and attended meetings to review this rich
material and identify the best excerpts, thank you so much.
As Principal Investigator, I would also like to extend a very special thank you to Guy Rocher, a
seasoned sociologist and humanist who has been closely associated with Qubec history for half
a century. Despite his many other commitments, he accepted to provide me with guidance in my
exploration of a discipline that I have been practicing for over 25 years and that I still love as
much as ever. Professor Rocher, your invaluable advice and suggestions have helped me dig
deeper into my subject, trust some of my intuitions and wander down paths that might otherwise
have gone unexplored.
We hope that this report will be of assistance to all the stakeholders involved in the current
reorganization of our health care system. It provides a better understanding of the issues faced in
family medicine and specialized medicine and makes an important contribution to the search for
innovative solutions.
Marie-Dominique Beaulieu, M.D., M.Sc., FCFPC

1. BACKGROUND, APPROACH, RESEARCH QUESTIONS

Everyone wants to head in the same direction,


but where are we actually going?
Closer collaboration between health professionals is regularly presented as a key
element in plans to provide the public with better access to high quality services.
But what do those primarily concerned think about collaboration?
Do they share the vision of the role that society wants them to play? Do they feel
adequately prepared to assume that role?
This study consulted two groups that will have to implement the current
series of reforms family medicine residents and specialist residents as well as
those charged with preparing them to step into these roles.

1.1 We have a consensus:


A new medical practice will play a key role in current reforms
Reforms implemented across Canada are trying to foster better access to quality care, care that is
more continuous and delivered more efficiently. Better integration of care and a more judicious
use of human resources are two of the preferred strategies advanced to achieve this end (1), (2),
(3), (4). There is a wide consensus that the success of these strategies will largely be based on our
ability to change current professional practices. To name just one of the arguments in support of
this thesis, it is worth recalling that a combination of demographic changes and technological
progress has now made managing chronic illness one of the major challenges faced by the health
care system. Comorbidity is on the rise (over 35% of adults between the ages of 60 and 69 suffer
from at least two chronic health problems; this proportion is 53% in adults over 80 years of age)
(5). We have a specialized model for the management of clienteles defined according to specific
health problems what is called disease management but this model is less appropriate for
managing multi-morbidities.
We therefore need to develop new models of professional practice, and a consensus appears to
have emerged on a comprehensive vision of future practice. Primary care services and family
physicians are in a better position to offer comprehensive care to patients and should be central to
this practice. Effective mechanisms for communication will ensure that information flows
between primary care practitioners and specialized services (6). In order to ensure that the
available expertise is used in an optimal manner, professional roles will need to change. Medical
specialists will need to stop providing follow-up care to patients who do not need their level of
expertise and concentrate on acting as consultants (even more than they do currently), providing
support to primary care professionals. For their part, nurses, pharmacists and other health
professionals will take on more responsibilities. For example, they will need to take on certain
1

roles that have traditionally been the domain of the family physician (1), (7), (4). Recent changes
introduced by the province of Qubec to the law governing health professionals have addressed
these issues, seeking the kind of flexibility that would foster these transformations (8).
Of course family medicine, often presented as a key element in the new care system, has not
escaped this trend towards redefining and adapting roles (9). In most industrialized countries,
professional organizations of general practitioners and family physicians have taken clear
positions by adopting a definition of the family physician in which a broad scope of practice,
accessibility to care and continuity of care have been presented as the very foundations of the
profession (10), (11), (12).

1.2 A growing gulf between the preferred vision and actual practice
There is a vision of future practice a practice founded on closer collaboration between the
various health professions, which then accept to adapt their roles that is clear and widely
accepted. In the field, however, actual practice does not appear to be moving steadfastly in this
direction. Indeed, practice is moving in the opposite direction.
While health care systems are ready to make considerable room for family medicine, the
profession does not appear willing to step in and adopt this vision. The actual number of
practising family physicians is in decline. Medical students are losing interest in family medicine.
Profiles of practice among general practitioners are tending toward narrowing the field of
practice. At a time when there is a general shortage of physicians, the profession of family
medicine has been particularly affected.

The proportion of Canadian medical students opting to study family medicine was 40% at the
beginning of the 1990s and had fallen to 28% by 2001 (13).

Changes in the profiles of practice of students graduating from family medicine programs in various
Canadian provinces reveal that a significant proportion of them (between 10% and 30%) are not
offering general primary care in the first few years of their careers (14), (15), (16), (17). This
proportion is as high as 56% among graduates who completed an additional year of emergency
medicine (18).

In Qubec, an analysis of the billing patterns of all general practitioners suggests that only 50% have a
practice corresponding to what we understand as family medicine: 25% have restricted their practice
to emergency and walk-in care, and 25% have little involvement in clinical care (19).

During the 2004 National Physician Survey (20), 13% of family physicians reported that they had
reduced their scope of practice over the previous two years, and another 25% said that they planned on
reducing their working hours in the following two years.

The situation is no better with respect to collaboration between family physicians and medical
specialists. Concerns had already been raised in 1993 with the publication of a joint study by the
College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of
Canada. It reported on problems achieving collaboration between general practitioners and
2

specialists, and underscored the existence of negative prejudices on both sides (21). The 2004
National Physician Survey indicated that the situation had not improved (20):

33% of specialist physicians reported that they were unable to see non-emergency patient referrals
from family physicians in less than three months. Only 25% could see an emergency consultation
within 24 hours.

30% of family physicians rated access to specialists as acceptable or weak.

50% of specialists qualified access to family physicians as acceptable or weak.

This gap between practices observed in the field and the proposed vision raises many questions,
particularly when we know that the vision is supported by leaders in family medicine. How do
family physicians, who will have to perform increasingly complex clinical tasks, see their scope
of practice,1 this key element of the practice of family medicine? What is their position on having
to share their privileged relationship with the patient in a team setting, where nurses and other
professionals play increasingly important roles? How do family physicians and medical
specialists see their collaboration and the role that each will need to play in a collaborative
practice?
This last issue begs the formulation of new questions. Until now, for the most part our attention
has been focused on collaboration between the professions. A major initiative has been launched
in Canada, with the objective of encouraging collaborative practice among professionals in all the
sectors of patient care (22). However, there has been much less interest in collaboration between
members of the same profession, as if collaboration between physicians is taken for granted.
Some experiments have suggested that this collaboration is anything but operable, and that
developing a collaborative practice between the specialist and the general practitioner is still
very much on the menu, with all the attendant hurdles to be crossed and therefore to be studied
and understood (21), (5), (23), (24).

1.3 The professional system: A useful tool provides a fresh look at


professional collaboration in the health care system
In order to examine this new collaborative practice, and in particular the roles that medical
specialists and family physicians will need to assume, we have adopted the systemic framework
developed for the analysis of professions by Eliot Freidson (25) and Andrew Abbott (26). This
approach takes both a concrete and penetrating look at the reality of professions and one that we
believe is not sufficiently known among medical professionals, whether specialists or general
practitioners. After giving due consideration to the general conditions of practice, we decided to
bend the law and the official position by treating family physicians and specialists as two
professions, professions that undoubtedly maintain close familial ties but that are in practice
quite distinct. We will consider their respective position statements as the official view of these
two professions and an expression of their preferred vision of practice.

In this report, references to scope of practice implicitly assume the goal of a wide scope of practice in family
medicine.

The family physician (27)

The medical specialist (28)

The family physician is a competent clinician (comprehensive


approach centered on the patient, expertise in a wide range of routine
problems and in emergencies).
Family medicine is a community-based discipline (practice
profile adapted to the needs of the community; unselected and
undifferentiated problems; varied practice settings; professional
collaboration).

The family physician acts as a resource to a defined


population of patients (practice as a population at risk).
The physician/patient relationship constitutes the essence of
the role of family physician (understanding the human condition;

Expert
Communicator
Collaborator
Manager
Health promoter
Scholar
Professional

providing continuity; defending patients interests).

The professional system according to Abbott and Freidson


The professional system is a collection of institutions through which members of an occupation
can move ahead in society by exercising control over their own work. This privileged position is
possible because the specific tasks that they carry out are different enough from those of most
other workers that members must exercise control over their own profession. The two guiding
principles of the professional system are based on the belief that certain tasks 1) are so
specialized that they are inaccessible unless one has the training and the experience to carry them
out, and 2) cannot be standardized. The idea of specialization, and therefore of expertise, is the
core of the professional system. However, this concept of specialization is quite relative;
someone who is considered a generalist in a given profession may be considered a specialist if
their expertise is compared to that of other professions.
Within the professional system, each profession is defined as a function of a group of tasks that
are themselves established by jurisdiction. Each profession must constantly defend its
legitimacy and its jurisdiction, whether in the public arena (before the general public, institutions
and the State) or in the workplace, the main arena where professional work is negotiated on a
day-to-day basis. This is where professional barriers are most poorly defined, particularly in
times of staffing shortages, when jurisdictions are most vulnerable and ground can be won or
lost.
A disciplines ability to justify and defend its jurisdiction depends on its capacity to clearly
establish its role and its effectiveness in the resolution of a series of problems. It is through
professional work, the professional tasks carried out by its members, that a profession can
establish its identity, its legitimacy and its jurisdiction in contrast with the other professions with
which it is constantly interdependent. These tasks have three bases: objective foundations,
subjective foundations and the ability to manage a system of specific codified or academicized
knowledge.

Professional identity
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 illness) or a cultural fact (such as aesthetics or spirituality).
The subjective foundations of professional tasks are grounded in practice and are the most
important bases of the profession. Abbott categorizes subjective bases according to the three
major phases in any professional work: the diagnosis and the treatment of problems, and the
process of inference.
Diagnosis concerns how we understand and classify problems. The classification system can
expose the profession to jurisdictional challenges. For example, the more a profession
restricts how a problem can be defined, the more it leaves room for another profession to
claim jurisdiction by proposing a more comprehensive solution to the problem. On the other
hand, the more vague the definition proposed of a problem, the more the profession leaves
itself vulnerable to another profession that would present a clearer and more precise definition
of the problem.
Two aspects of treatment can influence the vulnerability of a professional jurisdiction: the
effectiveness of treatment and its complexity. For example, the less a profession is able to
measure the efficacy of a treatment, the weaker is the professions claim to provide a true
solution to the problem. The easier a treatment can be provided, the more it can be routinized
and claimed by another profession.
The process of inference that leads to a diagnosis and associates the diagnosis with a
treatment also contributes to making the profession unique: the more direct the link between
diagnosis and treatment, the more vulnerable the profession becomes, because its tasks can be
standardized and delegated. The more the process of inference is complex and based on
abstract knowledge and the more the related judgments are discretionary, the less the
professionals position may be considered vulnerable.
Specific, codified or academicized knowledge. Professional work has direct ties to a system
of knowledge. Professional knowledge gives legitimacy to professional work by clarifying its
foundations and linking it to societys fundamental values, such as rationality, logic and science.
It is through codified or academicized knowledge that the efficacy of treatments can be
demonstrated. Thisknowledge 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.
A system of interdependencies
Professions are interdependent. The internal structure of a profession is only one of many
determinants of a professions ability to adapt to upheavals in the system, which is continually in
motion and never remains in a state of equilibrium for long. These upheavals, the constant
changes that can disturb the professional systems equilibrium, come as much from the external
environment as from inside any of the systems constituant professions.

The external environment includes the social environment and the cultural environment.
Among the elements of the social environment that can disturb the professional systems
equilibrium we should mention changing technologies and the organization of work, particularly
the rise of bureaucratization and the creation of very large organizations. But according to Abbott
and Freidson, the changes in the cultural environment play an even more decisive role.2 Their
discussion highlights three specific factors:
o The increase in the quantity and complexity of knowledge. Professions adopt different
strategies to deal with changing knowledge, and these strategies can have significant effects
on their jurisdictions. For example, the need to manage complex and abundant knowledge
may result in the creation of an expert system. This expert system, however, may make it
possible to routinize certain practices that may then be more easily taken over by another
profession. For example, the development of increasingly precise practice guidelines
undoubtedly contributed to the development of the role of clinical pharmacist by enabling
pharmacists to maintain that they are now able to treat patients and prescribe medication.
o Changing social values. Professions base their legitimacy on social values (what Abbott calls
the currency of legitimation). For example, science and efficacy are the social values upon
which the professional system has traditionally been based. They have gradually been
superceded by efficiency, accountability and integrity, and this has changed some of the rules
of the professional system. Specialization is highly valued at the expense of general practice,
a trend that harms family medicine. On the other hand, over the last few years we have
witnessed a return to humanism and community values, a trend that could result in family
medicine becoming more highly valued.
o The rise of universities. Historically, universities had to work their way into the professional
system, although they now provide most professional education. The relationship between
universities and the professional system is unavoidable, given the importance of knowledge in
professions. This relationship creates tensions between academics and practitioners in the
same profession; the former set the criteria of good practice by which the work of the latter is
evaluated.
Internal relationships between members of the same profession
One of the fundamental aspects of internal relationships between members of the same profession
is the ability of members to differentiate themselves from each other, assume a certain amount of
power and establish their own professional or personal path within a given jurisdiction. This
capacity for internal differentiation offers needed room for member autonomy and the pursuit of
personal aspirations, but it can also become a source of friction or tension. We will briefly
discuss four ways in which members of the same profession can differentiate themselves from
each other.
o Intra-professional status. Since a profession is organized around a system of knowledge,
higher status is bestowed upon those who are more involved in the organization of learning
and the generation of knowledge. This can be a source of problems or discomfort for
professionals working in the field. In the eyes of clients and members of other professions
2

For more information, read Abbott op. cit. Chapter 7: The Cultural Environment of Professional Development
(pp. 177-212) and Freidson, op. cit., Chapter 7: Bodies of Knowledge (p. 152-178).

with whom they have daily contact, practising professionals give the profession legitimacy
through their work. Yet within their own profession, practising professionals generally have
the least status, or at least they hold less prestigious positions than colleagues respected for
their scholarship.
o Differentiation of clienteles. The issue of differentiating clienteles can have considerable
impact. For example, some specialties or sub-specialties may abandon certain clienteles,
leaving them available to another profession. Abbott provides the example of nurses, who
entered the field of primary care after it had been somewhat abandoned by physicians.
According to Abbott, internal differences in status, combined with different clienteles and
different ways of organizing work, can create large disparities in income, power and prestige
within a profession.
o Differentiation of workplaces. Two dimensions are important here: the issues of income
(whether it is from an independent source or by salary, which carries less prestige) and type of
work (i.e. working in a group or alone). For example, in medicine the hospital has become an
important workplace, just as health management organizations have become in the United
States. As a result, physicians who practise outside these structures have lost part of their
prestige and power.
o Differentiation of career plans. Career plans are important because they can contribute to a
certain demographic rigidity that could make it difficult for a profession to adapt to changing
circumstances. For example, staffing shortages or surpluses will have an impact on a
profession and its role in the system.
Adopting this analytic approach to the study of collaborative practice inevitably leads to an
examination of the boundaries between the various professions, but we also need to look at each
professions functions, roles and identity. This last issue is particularly important, since
professionals can only develop effective collaborative relationships if they have, from the outset,
a good idea of their professions identity and its area of expertise. In order for collaboration to be
effective, one must be able to establish and assert ones expertise and acknowledge and respect
the others expertise. Interviewing physicians about collaboration therefore necessarily involves
asking them about how they see their respective role and professional identity. This is an issue
that has become more critical for family physicians at a time when the available data suggest that
they are deeply concerned about their professional identity.

1.4 Training: Where professional identity is formed


The training of professionals is clearly one of the factors influencing how the system functions.
In health, the educational system plays a particularly important role in how professional identity
develops (25), (26), (29), (30) and how professionals learn to collaborate (31). The
apprenticeship model used in medical training in clinical settings has a significant effect on how
physicians internalize professional roles (29), (30).

The initial training received by professionals is undoubtedly one of the main levers for
implementing collaboration in the health care system (22), (32), (33). But even here, observers
have underscored a break between the proposed vision and the reality of practice in training
environments (34), (35), (36). Does clinical training offer students educational settings and role
models that are appropriate to the modes of functioning we want to emerge in health care? Do
practice training environments enable students to acquire needed new habits, including learning
how to work in a collaborative practice? Certain programs have already responded to these issues
by introducing changes in direction, putting more emphasis on the development of learning
experiences in the community, in a rural setting and/or in a multidisciplinary context. The
development of attitudes and aptitudes for collaborative practice has become one of the stated
objectives of all the organizations and professional orders responsible for training health
professionals. In medicine, the Royal College of Physicians and Surgeons has identified
collaboration and professionalism as the fundamental competencies required in the practice of
specialized medicine (28).
Studying the professionalization process in medical specialties is not new; several sociologists
and educators became interested in the subject as early as the 1980s (30), (29). It is nevertheless
remarkable that these studies limited their examination of family medicine to a strict minimum.
This is probably a reflection of the level of interest for the discipline in health care systems that
are oriented towards specialized medicine. To fill this gap, we urgently need to know how
educators and young physicians reaching the end of their training (in family medicine and in
specialized medicine) perceive their respective roles in collaborative practice and, in addition, to
have their evaluation of the training they received to prepare them for these roles.

Summary
This study has heard from family physicians and medical specialists who have reached the end of
their training as well as their educators. It explored how these young professionals perceive their
future roles in a health care system based on collaborative practice, and how they see their
specific contribution to this new form of practice. More specifically in terms of collaboration
between family physicians and medical specialists, this study also seeks to deepen our
understanding of how various residency programs implement and attain training objectives
related to competencies in collaborative practice that the Royal College of Physicians and
Surgeons of Canada (28) and the College of Family Physicians of Canada (27) have identified as
priorities.

Objectives

Method

More specifically, the studys objectives


were:

The study was conducted in two phases that


ran from October 2003 to December 2004:

1. To survey training objectives with


respect to collaborative practice
competencies in four residency programs
(family medicine, general psychiatry,
internal medicine and general radiology)
in Canadas 16 faculties of medicine.

A mail survey was sent to each of the


four residency programs in the 16
faculties of medicine across Canada. The
selected programs comprised family
medicine and three other programs that
have strong functional ties to family
medicine and primary care medicine:
general psychiatry, internal medicine and
general radiology.

A qualitative study was conducted in


four faculties of medicine: Memorial
University of Newfoundland; the
University of Sherbrooke, in Qubec; the
University of Toronto, in Ontario; and
the University of British Columbia, in
Vancouver. These faculties were selected
according to two criteria: whether or not
the faculty had a stated community-based
orientation and how well the final
selection would represent the various
regions of Canada.

2. To select four of these faculties and


conduct a comprehensive study in order
to:
2.1 Explore how future medical specialists
and family physicians reaching the end of
their training perceive the role played by
their discipline in the Canadian health care
system and how they see their roles in
fostering an effective interface between
primary care and specialized services;
2.2 Determine the extent to which these
future professionals believe that their
learning experiences and their educational
institutions have prepared them to step into
these new roles;
2.3 Compare these perceptions with the
collaboration goals in their respective
training programs as defined in the
programs official documents and compare
these perceptions with the positions of
educators in charge of meeting program
goals.

The project was accepted by the Ethics


Committee of the CHUM Research Centre.
In addition, the qualitative sub-study was
accepted by the ethics committees of the
University of Toronto, Memorial University
of Newfoundland and the University of
British Columbia.

The mail survey. A letter was sent to all the


program directors requesting copies of learning
objectives for their residency programs. The
response rate varied between 60% and 80%.
The objectives were analyzed by two
physician-investigators (M.-D. B. and L.S.).
The analysis was based on the following
criteria:
The presence of objectives.
The type of objective: whether they were
institutional objectives, i.e. objectives prepared
by the institution itself, or the objectives of the
Royal College of Physicians and Surgeons.
The degree of specificity: a general objective
describes a comprehensive skill and a specific
objective describes expectations in more detail.
The description: the objectives were classified
according to whether they represented a
targeted general competency or intermediate
objectives for attaining the competency.
We also noted if the objective specified the
type of collaboration (interprofessional with a
family physician) that was sought. Finally, the
concepts of collaboration were listed and
classified as either traditional (leadership,
understanding of roles, teamwork, etc.) or
innovative (communities of practice, conflict
resolution, diversity and tolerance, etc.).
The qualitative study was conducted with focus
groups and individual semi-structured
interviews. In order to cover the entire
pedagogical chain, we approached four types
of respondents in each faculty:
o The vice-dean of graduate studies
(individual interview),
o The director of the program concerned
(individual interview),
o Faculty members from the program (focus
groups and individual interviews),
o Residents in each specialty (focus groups
and individual interviews).

Residents in family medicine were selected in


such a manner as to ensure representation of
the various training environments in each
program.
The interviews were led by three investigators
(M.-D. B., L.B. and L.S.). Group interviews
were attended by an average of three specialty
residents (out of a possible five eligible
residents) and an average of six family
medicine residents. Some specialty residents
were met in individual interviews. Interviews
with professors were either conducted in
groups (of three to six people) or on an
individual basis.
A total of 40 interviews were conducted with
91 participants.3
We reached saturation in terms of the points of
view expressed by our respondents (no new
themes emerged in the final interviews), with
the exception of radiology, where the
participation rate was not as high.
The results are provided, at times according to
the category of respondent and at other times
according to whether the respondents were
family physicians or specialists.
Finally, although we selected universities that
would enable us to contrast the results
according to a stated community-based
orientation, we found no differences in the
ideas expressed by respondents from these two
groups. Our findings have therefore been
presented giving no particular attention to this
parameter.

N.B. To simplify data presentation, we


have integrated findings from the analysis
of residency programs with findings from
interviews.

All the vice-deans of graduate studies and all the program directors (with the exception of two in radiology)
participated in the study. We met 16 professors of family medicine, 14 specialist professors, 25 family medicine
residents and 18 specialty residents.

10

2. FINDINGS

Training, practices and career choices


that do not always follow
the general consensus or the official view
Differences were found at various levels:
between family physicians,
between family physicians and specialists,
between residents and their educators,
between the official training objectives and the actual training received,
between the vision of the role of each party in a collaborative practice,
and among ideas on what consitutes collaborative practice.

2.1 What exactly is a family physician?


Two interview excerpts provide 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 patients age (pediatric,
adult or geriatric) or the illness. This requires a wide renage of skills because various approaches are
required. Sometimes family physicians provide curative care, sometimes they follow a chronic
illness or provide palliative care, where the focus is more on the patients comfort. As a family
physician, one has to be able to move comfortably through all this. In addition, sometimes you have
to defend the patients interests. There are times when the patient has trouble understanding the
system, knowing where to turn or how to access certain types of treatment or referrals. The role of a
family physician includes ensuring that the patient has all he may need in terms of treatment. Its
like explaining everything thats going on being able to educate the patient. (Resident in family
medicine)
I can see that family physicians are really the foundation of the family medical system here. They
provide treatment through the medical system. I think they also act as very strong advocates for
their patients. And in order to do that, in order to have continuity of care, the relationship with the
patient is very important. (Resident in family medicine)

Generally speaking, scope of practice, continuity of care and the relationship with the patient
formed the core of respondents definitions of family medicine. In terms of what we heard, there
seems to be a wide consensus among family physicians about the nature of their profession.
Although the view is widely shared, two different perspectives on the meaning of scope of
practice have been proposed.

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Some of the family physicians and most of the specialists we interviewed define the practice of
family medicine on the basis of the functions of the family physician, and they consider two of
these functions the ability to offer a first response to any enquiry from a patient and the
coordination and integration of the care experience as the disciplines foundation and core.
I think the basis of family practice is the continuity of care for the patient, and, of course, thats
medical care. But theres a whole lot of other things that enter into that, including the social context
and the psychological care. But for the most part, I see family practitioners as providing continuous
care, a kind of first-level entrance care for the patient. (Resident in family medicine)

Other participants based their definition of scope of practice on the 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 profession: it draws
attention to the responsibility of the family physician alone or in a group to respond to all
the primary care needs of his or her clientele and, in small communities, to respond to the needs
of the community as a whole. Respondents used the term full-service 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)

There are therefore two ways to look at the practice of family medicine, or the daily application
of this understanding of the discipline as expressed by a majority of our respondents (scope of
practice, continuity of care, relationship with the patient).
But independent of the criteria respondents used to define their professions, the interviews
revealed another split, one that appears to be both more significant and more revealing.
Ambivalence about scope of practice: the siren call of specialization
Although the majority of participants stated that a wide scope of practice is one of the
fundamental characteristics of family medicine (effectively agreeing with the dominant
professionnal view), their responses also very clearly revealed an enduring conflict between
scope of practice and expertise. This conflict, which captures the tension between family
medicines 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, its
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, its expertise as well. Its just to be feeling that Im able to do a
good job at everything. And I honestly dont feel that I can stay on top of it all, theres something that
has to be cut. (Resident in family medicine)

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I think part of that is for fear that its becoming so complicated that its hard to maintain your
competencies. Subdividing family medicine into family medicine, obstetrics or whatever. But
maybe thats what the future holds. Well, were already doing that to some degree, there are a lot of
examples of how were all already choosing a particular area of focus. However, I think in the training
program we still kind of encourage people to be generalists. I think theres a group of people who go
into family medicine because they see a holistic aspect related to health and human beings, one that is
lost in a specialists procedure on a coronary artery. Maybe there should be a sub-specialty of holistic
family medicine. (Educators teaching family medicine)

These doubts and this questioning leads future family physicians to conclude that the legitimacy
of a specialist will be more easily won than their own, even if they believe that their functions as
first respondent, coordinator and integrator are critical to the health care system.
I had specialist friends who said, Youre 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 all intents and purposes, to hear it from family physicians whether residents or educators
the degree of recognition accorded to specialization represents a thorn in their sides and a
constant source of concern. Some of them mention the extent of current knowledge, the way the
health care system is organized and their life objectives, and simply conclude that it is impossible
to sustain such a wide scope of practice. Even those who say they are comfortable with a status as
non-expert 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. I am considering obstetrics, and annual family follow-ups, and probably palliative care. I
do have adults in mind, I dont exclude them, but I would probably try to focus as much as I can on a
specific population. Because doing everything just seems too much. Considering my ability to absorb
information, I think that I could be a specialist instead of doing everything. (Resident in family
medicine)

We are supposed to know everything. That is what our teachers are telling us. Yet, the movement is
towards specialization. And I understand why My whole goal since being in internship has been to
try to figure out what it is Im going to eliminate from my practice, and what Im going to practise.
Thats been my goal: it hasnt been about keeping all my skills, but trying to figure out how many to
lose. (Resident in family medicine)
You just need to see both sides. No one nowadays can be a Jack of all trades. You have to maintain
your scope of practice, but not be excessive about it. (Resident in family medicine)
Were generalists. But we also have an opportunity to be a little bit of a specialist while being a
generalist. And I like that idea. I like the idea of knowing a little bit more about an area because, as
you said, we know a lot of things. But, you know, theres just no time. (Resident in family medicine)
In fact, I think the subtle message out there is still that if youre not doing comprehensive care like
what you might see in a rural community, youre not a family doctor. (Program director)

Finally, and still on the same theme, some respondents were concerned about the trend among
departments of family medicine to introduce third-year specialized programs:

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We are concerned about a trend in training in which departments seem to want to develop what I will
call the specialized family physician. We have also noted that many family medicine residents have
a tendency to develop an area of expertise. In my opinion, this is a misreading of the mandate or our
definition of the family physician, who is someone with a wide scope of practice, not someone with a
narrow or focused practice. I sense there is a movement in this direction, and I am afraid that we are
heading in the wrong direction, forming not family physicians but specialized family physicians
(Vice-Dean)

An enthusiastic commitment ... that we would just as well put off for a bit
This tainted ambivalence that one would maintain between scope of practice, an ideal that is
often considered unattainable, and expertise, a source of professional prestige, is in some ways
reflected in how residents view their entry into the profession: with an enthusiasm that is
tempered with a certain prudence.
Family medicine residents, well aware of the current staffing shortage, feel that they enjoy
considerable freedom as they set out on their professional careers. They are proud to be family
physicians and appreciate the diverse types of pratice the profession affords. Given their levels of
debt, financial considerations figure strongly in their choices.
Family medicine residents see two career streams. Some of them immediately begin a career in a
practice setting where they plan on having a career. For example, this is the case among residents
who set up practice in more remote regions, particularly in British Columbia and Newfoundland.
They are planning a very diversified career and opt for group practice. Others, a larger group, see
the start of practice as a point of transition. They do not want to commit to working with a
specific clientele, a group of colleagues or a community. Such a commitment is made even more
difficult by the fact that they still do not have much stability in their personal lives. They
therefore prefer having the flexibility to be able to try out several models of practice and to
consolidate (not lose) the hard-won skills demanded in hospital and emergency practice.
In my first year of practice Im going to be on a very steep learning curve. Ive chosen an
environment where I dont have to actually learn a lot about billing, either. Focusing on clinical
medicine is exactly what Id like to do, and not worry about the business aspect of billing. I went into
medicine because I like people, not numbers and that kind of thing. (Resident in family medicine)
The piece of advice a family physician keeps giving me is you just keep adding on as you go along,
and I think thats what Im really going to try to do when I start out: start out small and see fewer
patients and then, if I want to add, I can. Im definitely not in a rush to check into a practice because I
know how hard it is to relocate. So Im going to stay local for a while. (Resident in family medicine)
You have to figure out for yourself what you want out of life, out of your practice, out of your
different activities. Once these are established, then youre able to present it to your group and explain
it according to the situation, taking into consideration not only your realities and limits but those of
your community and the area in which you live and practise. (Resident in family medicine)
Because of all those unknowns, Im kind of torn between the decision to just take something thats
easy and thats already set up, versus going for something that I think I would like better but having to
deal with all the starts And also I think reimbursement is a big issue in terms of starting up your
own practice. I mean, youd have to see enough patients, working on a fee-for-service basis, to
actually pay the bills and make a salary, as compared to people who go into walk-in clinics where

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things are all set up for them and they can see more patients with less complex problems and walk
away with a better pay stub at the end of the day... Also, finding the right person to share a practice
with is another big issue. Would we be compatible? How would that work? Would the patients who
start out with me be comfortable seeing the other person when Im not there? Those types of
issues. (Resident in family medicine)

Changing values and aspirations across different generations of family physicians


Finally, this discomfort within the profession of family medicine has opened another gulf, this
time between young physicians who embrace the profession and physician educators who seem
to have difficulty letting go of the traditional view of family medicine.
Several residents therefore feel judged by their elders and their professors and report that the
latter adopt a kind of doubletalk. On the one hand, what family medicine educators say
encourages students to find a balance between their professional and personal lives. But in fact
the residents sometimes have the impression that they disappoint their elders and their professors
when they decide to restrict their practice.
Generally speaking and in contrast to their professors, the residents do not have the feeling that
there is a crisis in family medicine. Some of them feel guilty, or at least uneasy and torn
between two sentiments: a sense of responsibility to meet a societal need and fulfil the vision that
the discipline has of itself and a sense that it is impossible to do it all, to incarnate the entire
discipline in their individual practices.
This happened in just one day. I literally had a talk with a doctor who works part-time in palliative
care and kind of feels the same way I do about family medicine. And in the same day, another who
works in palliative care was quick to say, Those hobby doctors, they just arrive and theyre just a
hobby doctor, and they want to make the big bucks. But they dont want to work, they want to work
part-time, and no one is getting their work done... Within the same day, Ive been told, This is how I
chose to do it and why. I also realized that I will always have to deal with people who are thinking
that Im not doing enough work. (Resident in family medicine)
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
Im doing next year and I say that Im going to do OB and palliative. I feel they are disappointed if I
say, Oh, Im going to work in a clinic or do some walk-in shifts... Heaven forbid walk-in! Thats sort
of the subtle pressure: Oh, thats nice.... (Resident in family medicine)
I think theres 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 youre not living up to expectations if you dont practice in some other area of
medicine like palliative care, emergency or obstetrics or that sort of thing. (Resident in family
medicine)

For their part, professors also note this generation gap. They speak of a deep commitment to their
discipline. Several of them seem to be watching, powerlessly, as their graduates lose interest in
the model of the complete family physician. They speak of it with some regret and sometimes
with bitterness. They perceive this generation gap as a conflict of values.

15

One of the reasons Im 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 were spreading out their duties over a larger
group of people, both specialists and other health professionals. I think its 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 thats a challenge too, to teah people who do not
share your vision. (Family physician educator)

Fortunately, there is always the relationship with the patient...


Unable to define themselves in terms of a specific expertise, the traditional way professions
define themselves, family physicians fall back on what is generally considered one of the basic
characteristics of their profession: the relationships they establish with their patients. This serves
as an anchor for all our respondents in family medicine, both residents and professors. Family
physicians find their raison dtre in the relationship with the patient.
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 thats part of why you choose family medicine, as opposed to people who choose gynecology
or surgery. I really do, I think theres something about wanting to please people. Thats partly why we
choose family medicine. We love to be near people and then seeing tangible small-scale results.
Theres a relationship, a bond, and thats 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 main quality in the practice of family medicine, it can also be
peceived 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 youre worried about picking on patients you may not like.
(Resident in family medicine)

Has family medicine reached a critical threshhold?


All the physician educators interviewed, whether generalists or specialists, spoke of a crisis or
of danger. Several family medicine educators spoke of the profession as an endangered
species.
My fear is obviously that we wont have family medicine in ten years, that it will be all specialists or
GP-specialists. 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 whos probably going to make more and more use of the system over the next ten years...
(Family medicine educator)

However, others pointed out that the situation plays out differently depending on whether your
practice is in an urban area or in one of the regions.
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

16

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. So that is a very general statement about the urban
environment as I see it. Thats not to say that all family doctors are moving in that direction, but
increasingly it seems that its very difficult for a variety of reasons for family doctors to provide the
old traditional broad-based family medicine service. 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, and in some small communities
where family doctors do the whole range of family medicine plus anesthesia or advanced obstetrics.
So I guess I see an evolution in two streams: one is increasingly focused and the other is, in a sense,
increasingly broad: that is, in rural communities, as specialists tend to be either forced to rotate or are
voluntarily rotating through larger concentrations and larger communities. (Family medicine program
director)

Others are of the opinion that family physicians are condemned to an impossible practice, noting
how little the profession is valued in the health care system. Do we expect too much of the family
physician?
Its a very high level of responsibility to feel that you are responsible for all aspects of your patients
health and that you will be held responsible for it. So when your patient shows up in emergency with
an MI and its deemed to be because her LDL wasnt 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 its not appropriate to shoulder that
kind of responsibility, and they dont want to. (Family medicine program director)

Finally, many respondents believe that the trend towards specialization among family
physicians represents the real and principal danger to the professions survival, because the
system has a vital need for an integration function, and up until this point this function has been
fulfilled by family physicians. If they stop performing this function, someone else will have to
step in and take their place.

2.2 Collaborate? Sure, but who will do what?


Generally speaking, the respondents acknowledged that the question of collaboration between
family physicians and medical specialists was not a problem that captured their attention.
Collaboration is taken for granted. The professions may rub elbows and respect each other, but
they are moving down parallel paths. Even though all family medicine participants reported
positive experiences with collaboration, their experiences with specialists were generally quite
negative, and vice versa. Family physicians and specialists generally share a common
understanding of their respective roles, but their views indicate a certain frustration with respect
to how this role is performed. Respondents spoke of a growing distance between the two
professions in terms that revealed ingrained prejudices on both sides.

2.2.1 Similar notions


As we will see below, the interviews with participants revealed several inconsistencies between
the official view and actual collaborative practice, yet, contrary to what might have been
expected, these differences are not rooted in disagreement about the nature of their disciplines.

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The specialist: a consultant


Generally speaking, the two professions appear to agree on the role of specialists: physicians
treating patients with complex problems, facilitating access to specialized services, providing
information and acting as educators and consultants. In collaboration between the two
professions, it is the specialists role as consultant that comes to the fore. It was the psychiatry
residents who best expressed this idea:
When I discharge a patient and he returns to his community, I have to ask myself how his family
physician is going to handle it. Its clear that in this situation my team and I have a training role to
play, in addition to maintaining a certain presence in the case. We send the patient home, but if there
is any doubt or any type of problem arises, we are still there, because yes, there are risks. (Resident
in psychiatry)

Because the childrens hospital is a kind of unique resource, my part is more doing the
consultation, feeding back recommendations to the family doctor, and then, maybe, doing more
intermittent follow-up, like in three months or in six months, and checking to see hows the plan
going, making adjustments to the plan. Not doing the actual, immediate follow up. And then, with
the community mental-health team, I think theres also a role where I try to do some kind of training
and try to export some of the actual treatments. (Resident in psychiatry)

The family physician: the quarterback of the health care system


The specialists notion of family medicine is essentially the same as how family physicians see
their discipline, including doubts about whether it is actually possible to fulfil the role in practice.
Most of the specialist physicians interviewed, both the residents and professors, feel that it would
be impossible to provide the public with medical services without family physicians. The family
physicians expertise in evaluating and managing a braod variety of cases is widely recognized.
The functions performed (accessibility to, continuity of and coordination of care) are considered
vital. Specialists also acknowledge the unique relationship between the family physician and the
patient, a relationship that is built up over time.
Obviously, there are two different roles, and those two roles are equally important. 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. As I interact with family doctors as a specialist, I look at them as being
quarterbacks. The family doctor controls the overall care of the patient. In other words, he may
receive expert advice from a consultant or whatever, but Im talking about the ownership of that
patient, the primary care provider, the person who coordinates all the health care provided to an
individual: its the family doctor. (Director of an internal medicine program)
The core business is really the presenting physical complaint, or any complaint, in the context of
their family and general environment. Then, once you make that decision, as to where the issue is, you
as a family physician may not have time to pursue it. (...) So, what I would see as the core of family
medicine is really what is inherent in the name. One thing is continuity of health care. As specialists,
we are not in that business. They are the hub, in my opinion, of the health care system. We, as
specialists, are the spokes. We go into the various spokes. The hub of health care provision, in my
opinion, is continuity of health care. (Vice-Dean)
Compared to what we do, I think theyre experts in communication, and thats a good idea as it
relates to their patients because we (the specialists) have the luxury of being able to focus on an issue,
a specific issue, for the most part. But the family physician has to deal more with the patients and their

18

problems in the context of their lives over a long period of time. He has to take the time to build a
relationship thats therapeutic, a relationship of trust And you come to admire them for their
tolerance and their patience. I think thats what they do very well. And we could learn from that.
(Resident in internal medicine)
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 that.... Its incredible! In
fact, the scope of medical knowledge has become enormous. And we are asking people to master it
all... (Vice-Dean)

Other specialists presented a different point of view.


I dont think everybody should be doing everything. So I dont think the physician should be
delivering babies, seeing children, looking after an infarctus, going to assist surgery... I mean, theres
a reality that has to be faced: you need to divide your time. And I think that within a family practice
there are people who have technical needs, there are people who have psychiatric needs... So I think
that family practice trainees should gear their practice, to a large extent, around their interests. But
once their interest areas are defined, then I think they should be concentrating on an area that has
some component of another area. (Specialist in internal medicine)
I come from a different perspective because I trained in the United States and practised there as a
general internist when I did primary care. So I have bridged the gap (between primary and secondary
care) myself. I took care of the patients when they were in the hospital and I followed them as outpatients. (...) I think that in terms of taking care of adult patients, its a far better system. (...) But its
not the way the Canadian system is set up. Its just a different philosophy about how you do things.
But there is no doubt that theres a gigantic lack of continuity between what happens in the hospital
and what happens when people go to their family doctors. (Specialist in internal medicine)
I see family medicine as quite beleaguered. Burdened. And the burdens are multifold. One is that
urban family practice, in my opinion, has shifted, and it has shifted because there has been a
movement in the specialties to fragment. 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 arent available, so family physicians are burdened with having to do too much because
they dont have access to the many levels of specialties. (Vice-Dean)

At this point of our report, it is important to point out that the specialists we interviewed often see
themselves as powerless observers of the identity crisis in family medicine. Even though they are
affected by its repercussions, they do not feel implicated in the search for solutions. They only
ask thenselves where family medicine is heading.
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 dont quite know how we are going to get out of this
mess... (Vice-Dean)

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The wait-and-see attitude towards the condition of family medicine and the lack of interest in
participating in the solution that we observed in our interviews with specialists was confirmed by
a family physician in a strategic position.
Theres no incentive for specialists to change. I dont think that they would want to change, and, in
the current system, there would be no real motivation. I dont think they feel any altruism toward the
system or toward primary care, or any personal responsibility to make it easier for family doctors.
(Director of a family medicine program)

2.2.2 but somethings holding things up


There does not appear to be a major disagreement on the roles that each profession should play in
the health care system, working in the field; on the other hand, collaborative practice by the two
professions runs up against certain obstacles and does not always meet expectations. Issues were
raised about responsibilities, expertise, family physicians distancing themselves from the hopsital
setting, and changing roles (see Table 1).
Responsibilities: before they can be shared, they must be divided up
It was the specialty residents who had more perspective on the issues posed by working as
consultants in collaboration with family physicians.
In my two years as a senior resident, what I learned was how to be a good consultant. It isnt easy.
Particularly in internal medicine, where we want to do it all, control everything, while the consulting
role is about learning to be clear in our oral and verbal communication, to let people make their own
decisions while offering alternatives. I have seen practices where people didnt collaborate very well.
In addition to this being a problem in itself, it makes people in primary care afraid to act: they want us
to do everything. In other settings, we are able to talk to the family physician, even if he or she doesnt
have our level of knowledge in this specific area. When they did have enough knowledge, they could
discuss this or that aspect that we hadnt seen, as colleagues. We didnt try to impose on them, do
whatever we had to do and just leave them with the paperwork. When the family physicians
knowledge was incomplete, we explained things, knowing that there would be less need for our input
the next time around. (Resident in internal medicine)
Family doctors must realize that, when we do write back to give them advice, we expect that the
advice will be heeded. We do appreciate it when we send our advice in the form of consult letters to
family doctors and the advice is recorded and recognized. So I think that the family doctor and the
specialist must work together as a team, but we do have different roles. (Director of an internal
medicine program)

Once again, it was the psychiatry residents who had the clearest idea of the kind of expertise that
the family physician has and needs. In the relationship they establish with the family physician
the latter assumes the role of manager of patient care and the former acts as a consultant the
psychiatrists particularly appreciate two aspects of the family physicians expertise: their mastery
of physical medicine and their knowledge of the patient.

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Specialists are particularly frustrated by certain situations with or attitudes held by family
physicians: when they see that the patients health has deteriorated while in the care of a family
physician, when their recommendations are not followed and when the family physician is seen
as being cavalier in his or her approach to making the consultation request.
But the main problem for these residents has to do with their responsibility. Even though they
feel mutual respect and trust are very important, they believe the question of professional
responsibility lies at the heart of collaboration. In order to collaborate, professionals must be able
to clearly distinguish the responsibilities of each party.
Participants identified two fundamental dimensions: availability and expertise.
Availability. Both professions raised the issue of availability. The specialist, particularly when
dealing with frail and unstable clienteles, wants to be sure that the family physician will be
sufficiently available and have the resources to provide follow up care. The family physician
wants to be sure of having quick access to the specialist for an opinion and, if required, for a
hospital admission. Otherwise the result is the same: the physician is stuck with the patient and
must carry the responsibility.
Expertise. Rare was the specialist physician who, when asked about the nature of family
medicine, raised the issue of a lack of expertise as one of the professions limitations. On the
contrary, most deplore the trend toward restricted scope of practice, which paradoxically results
in specialist physicians providing primary care. On the other hand, expertise comes up again as a
key issue when they talk about conditions for effective collaboration between specialists and
family physicians.
They also mentioned:
Conditions of practice for generalists:
Actually, its getting more and more complicated, and it may be that general practitioners will have
to refer more, and certainly to interact more with specialists. You feel the pressure on primary care,
and it raises questions about their capacity to do everything in the time they are given. (Resident in
internal medicine)

Quality standards that appear sometimes different from their own:


The other issue with general internal medicine is oftentimes they refer a specific problem to us, so
we investigate it further. And in the process of doing the history and physical theres another issue that
needs to be dealt with or some unexplained weight loss... And I find that a little surprising sometimes,
to be honest, that a really obvious physical finding might have gone undetected, or the potential
implications of it were not identified. And the other thing that Im a little bit concerned about is
whether or not there are slightly different standards as well, depending on where you are. (Resident in
internal madicine)

Training issues, particularly with respect to the knowledge needed to follow the great chronic
pathologies such as heart failure and mental health problems.
I think that we have completely unrealistic expectations about what family practice doctors should be
able to do. (Specialist in internal medicine)

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Specialists isolate themselves


These criticisms of others shortcomings are not just a one-way street; family physicians also
have grievances about their specialist colleagues. They perceive a certain arrogance in the
attitude of these experts and mention problems gaining access when they need an emergency
consultation. Most of them complained of the profession being somewhat closed.
The specialists did not deny that these complaints could have a basis in reality. Several of them
mentioned a lack of resources in specialized practice (staff shortages) and some hospital
restructuring policies as important factors in specialized physicians pulling back and isolating
themselves. This phenomenon can take several forms: collaboration with primary care is not seen
as a priority, specialists do not feel that they need to answer to primary care, clinicians are
exhausted, and the available specialized resources do not meet the clinical needs of their own
patients. To this must be added ineffective communication systems; several specialists pointed
out that hospitals often begin their cutbacks in communication support services.
We dont have a good system for communicating whats going on in the hospital to the family
doctors. And a good hunk of that is our fault, I dont doubt it, because its a time-consuming process
to track down the family doctor, you know; theyre busy, theyre not in the office when you call them,
they call you back and you cant remember the specifics. You know, its a very tedious process and
not very many of them come into the hospital anymore to see patients. (Internal medicine specialist)

Far from view...


The notion of a certain distance appearing between the two professions was most strongly
expressed by educators in the specialty disciplines. They mentioned and often deplored the fact
that family physicians have pulled away from areas where they, the specialists, continue to
practice. This estrangement has been as apparent in urban hospital practice settings as it has in
training environments.
Family physicians have progressively abandoned hospitals to practice in the community. As a
result, they no longer rub elbows with medical specialists, who work first and foremost in
hospitals. Indeed, specialists highly value hospital work, as hospitals are important centres of
higher learning and specialized practice.
And thats whats been lost by the family doctors leaving the hospital environment. For all the time
they used to see their patients in the hospital, used to assist on their own surgeries and everything, they
developed relationships with specialists. They had that. (Family medicine educator)

A slightly cynical specialist added:


Their patients go to hospital, and they are the champions of continuity of care, but when their
patients hit the door here, for the most part the patients dont have continuity of care. When their
patient is discharged, they dont seem to pick up the continuity of care. (Specialist in inetrnal medicine)

The domino theory


Participants said they had seen a shift in, a new sharing of, even confusion over the respective
roles of specialists and family physicians. For the most part they attributed the change to current
medical staffing shortages. They described a paradox in the form of a domino effect: specialists
are leaving certain specialty areas vacant, retreating into overspecialization, while family
physicians are abandoning primary care and assuming more and more of the responsibilities that
22

have traditionally been the domain of specialists. But there are times when the opposite is true:
specialist physicians will invade a traditional area of practice of family medicine. There is,
however, one point in common: each group deplores the fact that the other is not playing its
role.
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)
We are now in what I would qualify as a major crisis. Were putting out fires: family physicians are
mainly providing specialized services because we dont have enough specialists. For example, we
only have one endocrinologist for an entire territory, so family physicians are taking care of the
diabetes clinics. And they do it very well; they have developed very good expertise in that area. But
while they are doing that, they dont have the time to follow patients in the office. Accessibility in
primary care? Its unfortunate for the patients, but they have problems finding a family physician.
They cant get access as fast as we might want. (Family medicine educator)
There seems to be little commitment on the part of many of the specialists to facilitating the care
provided at the primary care level. The specialists are spending a lot of time doing follow-up care that
probably should be handled by family doctors, and could easily be handled by family doctors, and it
consumes a great deal of their time. What we need is access or consultation, new consultation. And I
dont know if they do this because theyre reacting to the fact that many family physicians arent
willing to follow these problems, or because there are financial incentives because its simple to do
follow-up care and much more difficult to take on new patients. But thats whats needed in the
system, so perhaps they need to be compensated differently, one that would take away the incentive
for routine work and let family doctors do that and be available for administration. Thats what we
really need. (Family physician)
I think the most important group, the most important job in medicine is family practice, primary
care. Not because I did it when I started out, but because thats the really important job. That has to
be the sole way to integrate care, and it doesnt happen. Maybe for a variety of reasons. (Internal
medicine specialist)

2.3 Collaboration can be learned! ... Really?


Here again we had a consensus: collaborative practice between family physicians and medical
specialists will not be possible if practitioners in each of the professions have not been trained for
it. The academic community appears to be very aware of their responsibilities in this area, since
all the programs we studied comply with the directives of the Royal College of Physicians and
Surgeons and have objectives with respect to collaboration competencies. But setting objectives
is different from meeting them, and in the case of collaborative practice, our respondents believe
that this distinction persists.

23

In theory, vaguely stated intentions


All the programs that responded to the mail survey had established collaboration competency
objectives.4 For the majority of them these objectives were institutional, meaning that the
program had written its own objectives as a function of institutional needs. The majority of these
objectives identified terminal competencies rather than specifying intermediate objectives that
would lead to these competencies.
The objectives were generally based on traditional concepts, with little in the way of innovative
concepts of collaboration competencies. More specifically, if there was specific mention of
collaboration with multidisciplinary teams, very few institutions made explicit reference to direct
collaboration between the specialist and the family physician. Only four internal medicine
programs and three programs in psychiatry listed it among their objectives. References to
relationships with the family physician were usually found in the context of medical specialists
responsibilities in the training of generalists rather than in a context of a collaborative
relationship. The objectives therefore did not indicate notions such as community of practice, the
sharing of knowledge, conflict resolution, the delegation of medical acts to other health
professionals, multiprofessionalism or interprofessionalism.
The objectives were often succinct with little in the way of detail, leaving one to assume that
professors and residents are able to perceive clear and unequivocal expectations without precise
indications of what is needed in their particular specialty.
The analysis therefore revealed that educational objectives are not very explicit in terms of
professional collaboration. For all intents and purposes, consultation is the only collaborative
activity between a family physician and a medical specialist for which teaching has been
formalized.
It should nevertheless be mentioned that the physicians teaching these programs appear to be
aware of these shortcomings and limitations. One of them effectively summarized the view of
everyone we met: We pay lip service to collaboration.
In practice, collaboration left to its own devices
The residents we interviewed had not had formal experiences of collaboration between future
medical specialists and future family physicians. They interact when they are on call (generally
known as the junior/senior relationship). Together, they survive the training experience, this
common ordeal that at least helps break down their prejudices.
According to residents, professional collaboration is generally not a formal part of the clinical
rotations experience, with the exception being training programs in psychiatry. When
professional collaboration is explicitly discussed, it is collaboration with other professions rather
than collaboration between family physicians and specialists. Collaboration is therefore learned
on the job: for example, during hospital rotations. Experience varies in family medicine; the
residents who spoke of being exposed to collaboration with other professionals who were doing
rotations in innovative training environments.
4

Detailed results from the mail survey are presented in Table 2.

24

Pointing fingers at university hospitals


Where the training takes place appears to play a critical role in learning collaborative practice.
Residents have the perception that collaboration with primary care is not a priority in university
hospitals. Generally speaking, the family physicians we interviewed (residents and educators)
were very bitter about their relationships with medical specialists in university hospitals, so bitter
that they had difficulty taking some distance from the subject.
In almost all the specialized rotations, family medicine residents said that they heard their
specialist supervisors make offensive comments about the clinical conduct of community-based
family physicians, comments often made in the presence of residents in specialized medicine. All
of them said that at one point they had heard certain specialist professors denigrate their career
choice.
Family medicine is not well regarded anymore, and I think a lot of it starts early. In the education
system, we are taught by specialists. You dont see family physicians, you dont have any role models
when you go through training. (Resident in family medicine)
Specialists dont respect family doctors, you see it all the time. Were in a medical school thats
meant to produce family doctors, thats the model of our medical school. But were taught totally,
entirely, solely, by specialists, except probably for a month-long token visit by a family doctor.
(Resident in family medicine)

The family physician must be key, the central person for anyone entering the health care system.
Unfortunately, this role is scorned in university hospitals because there are just too many specialists.
The situation seems to be better in the regions. (Resident in family medicine)

Rotations in the regions generally seem to escape this pattern, offering positive role models to
residents in both family medicine and specialized medicine:
I am in a region. I find that during a rotation, residents really have a chance to get to know and work
with specialists. Here, as family physicians, we have very close contacts with the basic specialties,
including surgery, pediatrics and internal medicine. Residents have the same experience when they
start rotations. They have clinical responsibility for patients for example, when patients are
hospitalized and if they have a problem they want to discuss, they call the specialist in internal
medicine directly. The specialists in internal medicine, like all our specialists, are very open to direct
contact with residents. Even in Emergency, when they want to admit a patient, they will call the
specialist or the family physician directly. Even for specialty residents who do rotations here, its a
good experience because they dont often have the opportunity to see this kind of teamwork between
family physicians and specialists, with a case management role for the family physician and a
consulting role for the specialist. For residents, the best way to learn to collaborate is to do it during
their clerkship. (Family physician educator)

Not being familiar with the training of other physicians


Perhaps what we have just seen in the preceding discussion is one of the factors that has led the
majority of family medicine programs to pull their students out of rotations in overspecialized
disciplines, deciding that this training is not appropriate. One of the consequences of this decision
is that students in family medicine are mostly trained in community-based hospitals, where they
do not have much contact with specialty residents. They therefore deal with specialists who have
25

little contact with related university departments. The professors teaching in the residency
programs of both types of discipline therefore do not often interact with each other in joint
teaching projects. The result is that specialist physicians have a limited understanding of the
actual training received by general practitioners, and some of them have the impression that it is
training at a discount. Clearly this attitude does not foster healthy collaborative relationships.
I wouldnt have a clue as to where theyre getting trained, either in psychotherapy or social work
There hasnt been a single family practitioner to come through our training program in years, not even
taking it as an elective. So, to me, thats a real problem because I think family physicians do an
extraordinary amount of mental health care. But I would propose that theyre really ill-trained for it.
Ill go back to my first thing. I dont know if theyre trained for it. (Director of a psychiatry program)
Well, they do things, they suggest that their training program should be completed in the community,
so they disenfranchise their educators at the beginning and make them different from anybody else.
They say you dont need to know this, you just need to go to a community. (Internal medicine
educator)

This issue was brought up by several participants, irrespective of their field of specialty, but with
more intensity by certain professors of psychiatry. Several did not know what kind of training
residents in family medicine actually receive. Some of the psychiatrists we met questioned the
family physicians expertise with respect to the treatment of mental health problems and,
consequently, his or her ability to collaborate as a member of a mental health team. The
teaching of psychiatry has often been delegated to professionals who are not physicians (such as
psychologists and social workers) who teach in collaboration with family physicians. The
teaching of psychiatry has been based on a bio-psychosocial approach rather than the treatment of
the major psychiatric pathologies. Several participants questioned the absence of a required
rotation in psychiatry. In effect, the two departments are quite impenetrable in terms of teaching
as well as clinical practice. Some of our participants believe that establishing dialogue between
the two disciplines will be a major challenge.
The prestige of generating knowledge
Finally, certain specialists believe that family medicine has a lower profile in the academic
community because it does not contribute as much new knowledge as the other departments,
whereas this is what is expected of all academic physicians.
It has been an issue in the training program. Its been an issue because the specialists have not
viewed family physicians as being at the same level, not in their medical expertise, but because
theyre not doing the same kind of other academic work that the specialists are doing. I think as soon
as we see a family physician who is just as involved in scholarly activity, I think the equal, mutual
respect would be the same as two specialists talking to each other. Its not what youre called, its
what you do thats important.... We need to get them involved in scholarly activity so they will
become equal partners. There are a lot of reasons for that: its a shorter training program, the teaching
in family medicine has been practice-based instead of hospital-based, where the research is
happening... The lesson I learn from this is that the students look up to the role models theyre given,
and if the teachers are internists and surgeons with graduate degrees, these are the role models they are
going to look up to. So, its up to family physicians now, to a) want to teach in the undergraduate
curriculum and b) present models that the students will look up to and try to emulate. (Vice-Dean)

An internal medicine educator made a rather terse judgment about the superficial nature of the
knowledge that is provided to family physicians and that is to be used in decision making:
26

Because I remember going to one of their first conferences (since I was a family physician) and they
had a book called the Textbook of Family Medicine. They wanted to sell it to all of us there, and I said
to them, What good is this going to do me? I said, I live in a community where were the doctors of
the community and this is the Readers Digest of medicine. Thats good if you live in downtown
Toronto. And so this was the beginning of how family practice was guided, or misguided, into the
sort of superficial roles, the understanding that youve got your superficial knowledge. (Internal
medicine educator)

When the example is set by the leaders...


This distance we have seen between the two professions in their training has a parallel in the fact
that there are two systems for defining the functions of a physician, depending on whether you
are talking about a family physician or a medical specialist. The College of Family Physicians of
Canada provides a definition of the family physician based on four principles, while CanMEDS
2000 gives a definition of the medical specialist according to seven functions.
Oh, CanMEDS has seven roles, but Family Medicine has four principles... I know that there is a
turf issue here, but I wish the two colleges would get together and call their roles the same thing.
You know, the four principles have all of the CanMEDS roles in them. If you just break them down
you can find them. It would helpful if all our students would have all the same names for their roles.
We now have actually adopted the CanMEDS roles as primary initiatives in the undergrad
curriculum. It would make family medicine equal to all the other specialties, as opposed to being off
by itself. (Vice-Dean)
What would I do differently? I would take away the two-class system of training and make all
trainees go through much the same training. (Internal medicine educator)

2.4 Summary
Diverging views within family medicine
Family medicine is going through an identity crisis and seems to be hesitating between two
options: to maintain all the traditional roles or to abandon some of these roles, putting more
emphasis on others or assuming new roles.
The difference between these two options grew out of the fact that some family physicians,
particularly those starting out in the profession, believe that the desired scope of practice or the
function as the orchestra conductor, directing patient-centered care is an unworkable ideal,
given the unrelenting expansion of knowledge, the current organization of the health care system
and the quality of life they hope to achieve. Some of them seem to see a way out of this untenable
situation: developing one or more areas of expertise. They believe that having more expertise
would bring them a better quality of life and a new basis for their professional legitimacy. This
approach runs counter to the teachings of their professors of family medicine, giving a decidedly
intergenerational dimension to tensions inside the profession.
Even if family physicians seem to be seeking new professional legitimacy in the acquisition of
greater expertise, all parties still agree that the relationship with the patient is the foundation of
this legitimacy. Some family physicians seem ready to give up pursuing the ideal of a wide scope

27

of practice, but no-one wants to abandon their one-on-one dialogue with the patient. Those who
would limit their scope of their practice to a few specialized areas do not appear able to provide a
full appraisal of the practical consequences on their relationships with other professionals and the
rest of the system.
The gulf between general practitioners and specialists
General practitioners and medical specialists did not always explicitly mention the split between
the two groups, but all of their remarks on the distance between them clearly indicate that it has
been noticed by both groups in the workplace, in their training and in the generation of
knowledge.
An initial distance was created in the workplace when family physicians gradually left
hospitals to practice in private offices and in the community. As a result, they no longer see
medical specialists on a daily basis, because specialists are primarily based in hospitals.
Specialists place great value in their hospital work, as hospitals are great centres of higher
learning and specialized practice. The abandonment of hospital work has created the perception
that the general practitioner has abandoned part of his or her expertise.
A second distance, one between the types of training given to the two disciplines, was
expressed more clearly than the other two. Family medicine programs generally took their
students out of overspecialized rotations, which represented training that they considered
inappropriate for their future graduates. Now the faculties of the two disciplines hardly interact at
all in their academic activities. Their forums for discussing the curriculum are often distinct. It is
the professors of psychiatry who are most acutely aware of this distance, which is well illustrated
in the two separate systems used to define the functions of the family physician and the medical
specialist. As a result, specialists are unfamiliar with the actual training received by general
practitioners and have the impression that it is training at a discount. This view has not escaped
the notice of family physicians, who see it as a kind of contempt, particularly in the university
hospitals.
Finally, there is a third distance between generalists and specialists, related to the generation
of knowledge. Several specialists thought that the contribution made by professors of family
medicine is insufficient and not as significant as the effort they bring to generating knowledge,
one of the roles of any academic physician.
Specialist physicians are interested in the questions being raised by their colleagues in family
medicine, but do not feel part of the solutions. They feel strongly about family physicians
maintaining their scope of practice, a function they consider an essential part of the system.
However, their attitudes in educational institutions and collaborative practices indicate that a
wide scope of practice does not carry the same prestige as having advanced expertise and
knowledge in a given field.
The gap between planned training and the training actually received
Despite having adopted professional collaboration objectives, university training programs, in
their teaching and in their rotations, are not the crucible of mutual understanding and
collaborative practice that they should be. University hospitals in particular appear to be poorly
suited if not simply hostile to family medicine.
28

Based on remarks made by residents and educators, we have identified a series of pitfalls in the
teaching of collaboration between the family physician and medical specialist. These pitfalls vary
in nature, but they all influence, directly or indirectly, collaborative practice:

Collaboration with family physicians is not discussed by the medical specialists who teach in
university programs. This aspect of practice has no standing in the career profiles of academic
clinicians.

Specialty residents are often exposed to professionals who provide negative role models,
criticizing family physicians and contradicting the official view.

There is a split between the residency training programs in family medicine and the
specialties, and this hinders the development of a coherent approach to collaborative practice.

In order to develop their expertise, specialist residents must learn to follow simple cases and
be exposed to the natural course of a disease in different degrees of seriousness. This forces
specialized training environments to maintain minimal primary care functions for purely
pedagogical reasons.

The organization of hospital work in large urban centres and university hospitals does not
give value to links with primary care.

In order to truly innovate in training for collaboration, university hospitals would need to
change how they organize work, and this appears to be a very arduous task.

Finally, the difficulties encountered in learning collaboration may simply reflect a larger
problem that is rooted in communication.
That raises a bigger question about how we manage information in all of medicine, how we manage
information within hospitals, between institutions, between primary care in hospitals with pharmacists
and other allied health care providers. What we have in this country, this system as it is, are silos of
excellence that dont talk to each other or cant talk to each other. Every hospital has a different
computer system. Were incompatible in talking to the pharmacist, so its either got to be through a
letter, which takes two weeks to get anywhere, or through personal phone calls, if you can get past an
answering machine. Its terribly frustrating, and I think it is one of the great impediments standing in
the way of efficient, good care. (Resident of internal medicine)

29

3. OPTIONS

Systemic problems require


system-wide solutions
There are no quick-fix solutions to systemic problems.
The solution will not come from any single stakeholder or even from the various
professions concerned, but will require a series of interventions implemented
simultaneously, at various levels and in different areas.
Our findings may appear pessimistic, yet our respondents have suggested several avenues for
solving these problems. We begin this section with their suggestions and then provide our own
proposals, based on a thorough analysis of the interviews according to the systemic theory of
professions that we used as a framework.

3.1 Respondents proposals


According to our respondents, the main challenge facing family medicine will be to demonstrate
that it can deliver high-quality, comprehensive care. This is no small matter, since comprehensive
care represents one of the most demanding forms of practice.
I think theres an awareness that comprehensive care is difficult. Its a very high level of
responsibility when you feel that you are responsible for all aspects of your patients health, and that
you will be held responsible for it. I think that this concept will work well if we really are attracting
into family medicine those people who are committed to providing high-level care to patients who are
both well and sick. Im not sure thats exactly what were seeing. (Director of a family medicine
program)

In order to rise to this challenge, several conditions must be established. With this in mind, the
respondents identified the following main actions.

Create new practice models for primary care where future physicians can be trained.
We need to develop new organizational methods that will include a significant investment in
interdisciplinary practice and participation in community-based accessibility networks. Family
medicine must assume a leadership role in these changes. Educational institutions must become
sites for the implementation of new models.
We need plenty of models of physicians out there, people who can make it work so that our learners
can see that you wont burn out. We want to create a model of a position thats more sustainable,
really. (Director of a family medicine program)
I think we need to move more into a different kind of public care delivery: group practice. (...) I dont
think its just medicine. And its not just family medicine. Some of our program director colleagues in
the specialties know its true, that their graduates are making narrower and narrower choices. So,

30

either were 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)

This excerpt from an interview with a resident illustrates how new modes of practice provide
positive experiences:
Personally, I did my rotations in an family medicine unit that was one of the first f amily medicine
groups to set up a real system with nurses. It was great. They had protocols, they followed diabetics,
they even had nurses who screen for STDs. Right there, that cuts down on walk-in consultations, it
represents a small reduction in the workload of physicians. I think that this model is worth
implementing. (Resident in family medicine)

Redefine the roles of the family physician and other health professionals: in particular,
the nurse.
Most of the specialists we interviewed believe that the family physicians expertise should focus
on managing patients with chronic illnesses and complex problems, particularly in the context of
interdisciplinary practice. Family physicians should concentrate on the more medical aspects of
the role (diagnosis and treatment) and leave prevention activities and more technical acts to other
professionals.
The future is such that there are probably going to be fewer family doctors per population to serve
peoples needs, so the family doctor is going to have to be able to assume different duties. And duties
that perhaps they have right now will go to other health care professionals. Well, things like routine
check-ups. (Internal medicine educator)

Specialists believe that in order to redefine the division of work, family medicine needs to enter
into a dialogue with nursing. Several of them gave the example of what is happening in their
specialty, where many tasks are being delegated to nurse clinicians and nurse practitioners. The
specialists saw this as one of the major challenges to ensuring the survival of family medicine.
I think medicine and nursing are two solitudes. There is certainly much more overlap between family
medicine and nursing at the clinical ground. Hopefully there is a lot of talking going on there. Given
human resource shortages, particularly, we really should be looking at enhancing the nurse
commission. () The sticky point there is the overlap between the nurse practitioner and the family
physician, and the relationships and roles and so forth. () I would argue a bigger issue: why do we
have the nurse practitioners and family physicians if theres so much overlap; I mean, why do we need
two streams that in a way are going to collide with one another? (Vice-Dean)

For their part, family physicians say they regret the need to abandon certain areas of practice to
other professionals, since these areas are very gratifying. In addition, the time spent in prevention
and routine follow-up builds their knowledge of the patient and establishes a long-term
relationship, one of the fundamental characteristics of family medicine.
The special thing about family medicine is that we also build a relationship with our patients. If we
turn to a more mechanistic way of working, which might be more productive, we could lose that sense
of bonding, that relationship in which we ask them what the problem is, and so on. That is part of the
human process, and it shows that we care. (Resident in family medicine)

31

Respondents feel that collaboration between family physicians and nurses is more difficult than
collaboration between specialists and nurses, since the boundaries between these two professional
roles are less clearly defined.
I think that it is the physicians who really have the most work to do in developing interdisciplinary
skills. Weve got our work cut out for us. There is the issue of culture, particularly for the nurses.
Nurses are used to working with specialists, and often they like that better because the work is so
precise The work is very clear; the roles are validated. A family physician can see an infant with
respiratory problems and then see an elderly person. Its such a wide range for nurses. Its difficult to
manage. You have to understand that all these different treatments... Whereas in a specialized clinic, a
breast clinic, for example, its much easier. (Family medicine educator)

Promote the scope of practice in family medicine as the main appeal


For several of the physicians, this redefinition of roles as part of a reorganized and
interdisciplinary practice does not necessarily mean that family physicians must abandon a wide
scope of practice. In fact, the opposite is true. Far from seeing it as a burden, they claim it is the
aspect of their practice that is meaningful and interesting; they see it as a source of pride.
There are so many opportunities in family medicine to really do a lot. The downside is that
sometimes youre not as well respected or as well paid as the specialists. But I think in terms of
personal satisfaction in your job, you have good relationships with patients and you have an
opportunity to really make a change in the middle of your career and do something different.
(Resident in family medicine)

I think that family practice is very exciting right now, simply because the scope of it allows you to do
so much. I think that that in itself should be exploited in terms of recruiting family physicians.
(Resident in family medicine)

Some residents mentioned that exposure to a positive role model in the form of a family
physician with a broad scope of practice played a crucial role in their career choice. This was
sometimes combined with practice in a non-urban setting, which is seen as more gratifying than
practice in large urban centres in terms of the quality of the professional life it affords.
Here everyone still does full-service family practice, and its a very good community in terms of the
interactions between specialists and family physicians. Were all very close and we all hang out on a
social basis as well as at work, including the residents knowing the staff physicians. So I think Ive
been exposed to different things in my training than other people, and Im hoping that that wont
change over time. (Resident in family medicine)

Change the conditions of practice and how the health care system is organized
One of our respondents identified three issues in collaboration between primary care and
specialized services: collaboration between physicians, collaboration between primary care teams
and specialized care teams, and primary care access to specialized care resources.
Clearly these issues involve personal factors (a need to change attitudes or habits, a willingness to
try out new roles, etc.), but individuals will not carry all the responsibility for making
collaboration a success. Even if they are willing to collaborate, organizational action is also
necessary.
32

We therefore need to have a health care system that does not just pay lip service to the value of
primary care. Investments must be made in primary care infrastructures and in professional
compensation.
I think family physicians are relatively underpaid. I think the Ministry and the provincial medical
organization that negotiates these issues are finally beginning to realize that, and that the next contract
signed will probably show some improvement for family medicine. (Vice-Dean)
My 'cynical' view is that the government will not invest anywhere near the amount of money needed
to make these things happen. The physicians themselves will not develop these centres. Unless theyre
government-sponsored and government-developed and funded, and include all of the other health
professionals. (Director of a family medicine program)

Similarly, we need to address the lack of resources in specialized care (in particular, the shortage
of personnel) and reconsider certain hospital restructuring policies, two factors brought up by
several specialists who said that they had a significant impact on specialized medicine becoming
more isolated.

Develop a sense of community in the medical profession, bring primary and specialized
care together in joint political action
What came out most forcefully in the interviews was the need for organized action at every level.
Not only do solutions need to be designed and implemented with the whole network in mind, but,
above all, the isolation of family medicine, on the one hand, and specialized medicine, on the
other, must come to an end, even if we understand the historical reasons behind it. From now on
the respective stakeholders family physicians in primary care and specialists in specialized
services need to work together and undertake joint political action if their demands are going
to be heard and understood.
The understanding, the politics of family medicine and of specialized medicine, need to be revisited.
But again, I think that we just need a recommitment to what physicians are all about. (Internal
medicine educator)
That sort of woke up the Chair of the Department of Medicine, who realized that this is not only a
family medicine problem. There are not enough family doctorsyou cannot attract people to family
medicine. This will affect us (specialists) and the rest of the system. So we all have to get behind
efforts to fix this problem. (Program director in family medicine)

Universities have a responsibility to play an active role in the health care system and promote
innovative models that will foster integration with primary care.
The overriding policy for primary care comes from the government. Its a political issue first, and we
are the ones who translate this into action. So, its clear that the Ministrys primary goal for the health
care system is to make primary care the point of entry into and the coordinator of the system. So we
respect the Ministrys initiatives, and we try very hard to accommodate them. (Vice-Dean)

33

Act upstream, starting with training, educational institutions and clinical rotations
Respondents proposed a series of measures, all of which concern the training received by
physicians and the settings in which it is given. Here we will limit the discussion to a list of these
measures, although some of them are examined in more detail in the following section.
To counter the divisions that are set up at the beginning of medical studies and that become
more pronounced in residency, some respondents believe that it is essential to bring an end to the
discrepancies between current sets of objectives those presently promoted by CanMEDS
2000 and those of the College of Family Physicians of Canada. These discrepancies support the
idea of two distinct cultures and compromise some of the educational initiatives introduced by
faculties of medicine, initiatives that could be useful in structuring collaboration, whether the
collaboration is between professors or between residents.
Medical training must give more value to family medicine. This presupposes that the faculty
makes a commitment that is clear, beginning in the pre-clinical years. Offensive comments about
family physicians must be denounced as unacceptable.
Clinical teaching must emphasize role models and supervision. This will require making skills
explicit from the outset and modelling them as well as the desired collaboration behaviour
(deconstructing collaboration).
The current curriculum must be re-examined with a view to ensuring that residents in family
medicine and the specialties receive joint training.
We must create clinical case-management experiences where there is sharing between
educators and residents. This may even require reorganizing the work and may mean, for
example, that specialists are sent into primary care settings.
We must create new settings for clerkships, ones that resemble the desired models more
closely.
The family physician must contribute to the generation of medical knowledge. Scholarclinician role models must be developed.

Summary
The solutions suggested by our respondents resemble in many ways the recommendations of
various working groups and task forces in Qubec and Canada (37), (3), (2), (4): the creation of
new practice role models, a redefinition of professional roles, and improvements to conditions of
practice in a network that does not yet place enough value in primary care. Two elements stand
out: (1) the importance of considering training environments as the preferred laboratories for
change and, consequently, of giving priority to these environments as places for testing new
practice models; and (2) the need to develop a vision and concerted action within the academic
medical community. In addition, although there may be consensus on the need to redefine
professional roles, the view held by some family medicine educators and residents suggests that
collaboration with the nursing profession is sometimes seen as a handing over of traditional areas
of practice that are widely valued.
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3.2 Our proposals


Not only do we need to review the functions and roles in family medicine and the other
professions, we also need to reconsider how clinical practices, services and professional training
are organized. Clinical practices cannot be modified without changing the way we train
professionals, and vice versa. Similarly, we cannot modify clinical practices without changing the
way we organize those practices and services, and vice versa.
The physicians we interviewed formulated several proposals highlighting promising directions
for solutions. Some of the proposals have already attained a wide consensus. Our goal here is not
to analyse these proposals, settle anything or decide which proposal may be better. Rather we
propose a thorough examination of the issues, one that is largely inspired by the proposals, yet
considers them under the systemic view of professions that served as our analytical framework in
this study (Chapter 1, Section 1.3). Through this framework we have posed certain questions and
developed a series of proposals. Some of the proposals address the larger issue of the identity of
family medicine as a profession; others concern professional collaboration, the organization of
the overall health care system and training environments.
Understanding the identity crisis in family medicine and helping family physicians assume
their role in a new context
The theme of family medicine at risk was evoked by most of the educators we interviewed,
whether they taught family medicine or a specialty. Our analysis of the interviews based on
Abbotts framework has led us to formulate proposals that take into account the nature of this
crisis, its causes and the least perilous means of getting through it.
The identity crisis in family medicine and the tensions among its members, torn between two
trends, are even more difficult to resolve because the causes are not inherent to the profession.
Taking Abbotts view, a series of changes in the social and cultural environment have created an
upheaval in the system that is forcing the profession to reconsider its functions.
These changes are products of evolving technologies and the reorganization of work. For
example, the development of diagnostic and therapeutic technologies as well as expert systems
have introduced a certain routine into some of the family physicians acts and facilitated their
delegation. Similarly, the reorganization of the health care system has resulted in a formalization,
even a certain bureaucratization, of practice, particularly in primary care, that medicine in the
liberal tradition has been hesitant to embrace. While other professions such as nursing and
pharmacy see these reforms as an opportunity to enrich their roles and are therefore more inclined
to embrace them, family physicians are more likely to perceive the reorganization as a source of
uncertainty and challenges (38), (39), (40). Family physicians have come to be seen as the
professionals who are the most difficult to bring on board and are often identified as standing in
the way of a reform that decision makers uniformly consider essential. Finally, specialization,
which wins some points for its cultural value, has seeded a certain amount of confusion in the
profession, creating doubt about the foundations of family medicine, since specialization as a
societal value seems to take precedence over other values such as humanism and a judicious use
of common resources. The latter values are areas in which family medicine is known to perform
well, and to the profession they represent a traditional source of value.

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Not only are the cultural foundations of family medicine undermined by technological
developments and the organization of work, but the subjective foundations on which it has
traditionally defended its legitimacy have also been shaken. In diagnosis and treatment, general
practice has long been positioned as having expertise in the management of routine and poorly
differentiated problems as well as chronic problems (10), (11), (12). For the last few years, the
effectiveness of family medicine in the management of complex health problems (in particular,
chronic health problems) has been contested (32), (41), (42). There is now a significant body of
research comparing the effectiveness of treatment by general practitioners with treatment by
medical specialists (43), (44), (45) and other professionals, in particular, nurse practitioners (46),
(47). The findings suggest that approaches used by general practitioners are less effective.
In short, we observe that, strictly from the point of view of interprofessional relations, general
practice has found itself 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.
The fundamental issue is therefore how the profession of general practitioner should react to
these changes in its environment. As we have seen, until now there have been two broad trends,
trends that are divergent and therefore represent a source of tension. On the one hand, there is a
tendency to want to preserve all the functions traditionally assumed by family physicians by
adjusting them to the new context of practice. This is the dominant professional view that, in the
end, confirms that the practice must change, but without the profession letting go of any of its
traditional characteristics. On the other hand there is the tendency to lean towards giving up the
important role played by a wide scope of practice (as the orchestra conductor) and limiting
ones action to a few areas of expertise.
We believe that a third path presents itself, one that would enable the profession of general
practitioner to play the role it merits in a renewed form of primary care based on closer
collaboration with other professions. It is possible to achieve this without letting go of the
professions scope of practice, which we believe is its most fundamental function. However, to be
in a position to fulfil this role, family physicians will have to agree to abandon their monopoly
over the patient relationship, and accept that this relationship can continue to be a privileged one
without continuing to be exclusive.
We need to think through the consequences of the two views of the family physicians scope of
practice: one where scope of practice is understood as the ability to manage and coordinate all
of an individuals health problems, and one where scope of practice is understood as the ability
to act in primary care as well as in secondary care -- in short, to be present everywhere in the
network. Family medicine is not the only profession concerned with this issue, even if it is
attached to a view of the family physician as someone who can assume all medical functions for a
community. This issue must be dealt with by all the stakeholders concerned, since the solution
will depend on how human resources are deployed, not only in primary care but also in secondary
care. Canada is one of the few industrialized countries to depend so heavily on general
practitioners for the delivery of secondary care. This issue has yet to receive much attention, and
professional associations should approach it with care. Qubecs Federation of general
practitioners recently sounded an alarm on this issue (48).

36

To abandon a wide scope of practice is to test the very foundations of family medicine
The contributions of general practitioners that can be qualified as original, unique and
irreplaceable are their analysis of problems and their therapeutic approach, which goes beyond
the strictly medical, incorporating medical issues into a bio-psychosocial approach (49), (9),
(50). This is why over the last few years the issue of complexity has been central to arguments
defending the importance of the family physicians role and the professions legitimacy with
respect to medical specialists and other health professionals (51).
This issue of complexity merits a thorough analysis, which would probably bring out
complexity and its paradoxical side. Complexity is malleable and elastic, making it possible to
evoke complexity in defence of a thesis and evoke it again in defence of the opposite thesis.
That is why it has been said that the diagnosis and treatment of several problems has become so
complex that they can only be treated by a specialist. The tendency to emphasize the highest level
of specialization, to develop what is sometimes called a specialized family physician,
constitutes one of the responses to these emerging challenges, a response that seems particularly
attractive to not only a new generation of family physicians but also to some specialists and
administrators (52). However, one could also conclude that the family physicians scope of
practice represents the most promising solution to how we handle the growing complexity of
health problems, in particular the co-existence of several health problems in one patient. A wide
scope of practice therefore becomes a defence against the fragmentation that comes with
specialization (5).
The profession of family physician must not abandon a wide scope of practice. Until now, the
family physicians scope of practice has defined the profession, and we believe that it continues
to be the professions fundamental characteristic, much more than the relationship with the
patient, which many other professions can also claim. Indeed, we often believe that it is the
privileged relationship that family physicians establish with patients over the years that enables
them to play a central role in the continuity and integration of care. Like Freeman et al. (53), we
believe that this intimate knowledge of the patients condition, acquired by the family physician
over the years, is the result of his or her scope of practice the generalist aspect of his or her
practice. It is precisely because of this generalized and comprehensive view and approach that the
patient consults with the family physician on an ongoing basis and a relationship of trust
develops. The family physicians scope of practice precedes, explains and creates continuity,
integration and trust. Without this scope of practice, the chain is broken.
Specialization, a dangerous path into a dead end
In this sense, we believe that speaking of a specialized family physician (or quasi-specialized
or semi-specialized) will inevitably lead to an implosion or erosion of the profession, since it
removes the professions fundamental basis and the glue that binds it together: the
comprehensive, multi-faceted nature of its view and therapeutic approach.5
Family medicine must resist the temptation to become a specialized profession, a new trend that
provokes opposite reactions in the profession (54), (55). It must be recognized that this tension
between expertise and scope of practice indicates a strong social trend in favour of specialization.
At that point, the question becomes: how can we re-establish equilibrium between this trend,
5

We would refer the reader to Abbott and his analysis of the impact of internal differentiation as one of the main
forces in the implosion of a profession. Ref. Abbott A, op. cit. p. 117, p. 133.

37

which is producing a groundswell against which no profession is safe, and another social trend
that is clearly trying to redefine health as a function of our ability to intervene, but also as a
function of values honouring democratization, accountability and justice? Should it not be
possible for family physicians expertise to be located in their scope of practice, without them
becoming specialists per se?
On the other hand, does maintaining scope of practice as the chief function of the profession
equal preserving the status quo?
We cannot endorse the position of those who would keep things just as they are in general
practice, believing that all it will take to resolve the current crisis is more effective
communication between professionals. We think that residents are justified in seeing this as an
unattainable ideal, particularly when many of them find that the goal is out of reach, and they are
not even interested in trying to attain it.
It is therefore necessary to effect changes in the practice itself. We believe that the solution lies in
reaching a new understanding of this scope of practice and the relationship of trust between the
family physician and the patient.
When did privileged and exclusive become synonyms?
It is important at this point to return to the relationship between family physicians and their
patients, as it remains the professions founding experience and its last stronghold in the face of
challenges to its uniqueness. It would appear that, at the limit, family medicine has been taken
hostage by this relationship which, it bears repeating, is one of the four underlying principles of
the discipline. We can understand how professional collaboration can come to represent a threat,
particularly with nurses who place just as much value on their relationship with the patient and
who also can claim a holistic approach. Family physicians must accept that the patient, even one
with whom they have built a privileged relationship over time, does not belong to them. They
may very well exercise a comprehensive function with the patient, but this does not give the
family physician a right to an exclusive or even a predominant responsibility for the patient.
Other professionals are involved in patient care, fulfilling responsibilities that are just as
important to the pateints health and well-being, getting to know the patient and being able to
build a relationship of trust that is comparable to what the patient experiences with the family
physician.
We believe that sharing the patient relationship with other professionals is the most effective
strategy for preserving the fundamental uniqueness of the profession of general practitioner
the scope of practice, the comprehensive view of a situation, the privileged point of view for
ensuring continuous and integrated care and for taking into account the pressure exerted by
other health professions to ensure that they too will hold on to their responsibilities.
Redefining professional roles: it takes two to tango
Remarks made by our participants indicate that prejudices are still a problem on all sides. These
prejudices are supported by the perception that there is a significant gap between each
professions official view of the situation and the actual practices of their members, and by the
variety of perceptions of each professions roles and responsibilities. For the health care system
38

as a whole, the issue of professional roles is rooted in fundamental issues of professional identity.
In each workplace, the issue of professional roles is related to the need to clarify what concrete
form collaboration will take: in particular, to define the boundaries that establish professional
limits.
Family medicine is not the only profession that will have to change and adjust to a new reality.
Even if this study has focused on future challenges in family medicine, it is clear that the nursing
and medical specialist professions, among others, will face equally critical issues.
The nursing profession is going through significant transformations and is also redefining itself
and experimenting with new roles. These roles are often described in terms of the intersection of
and the interactions between systems (the person and his or her family, group, community and
environment) or as a transition between two stages of development, life experiences or life
cycles. For their part, specialists will need to develop their role as consultants.
These redefinitions must also take into account relationships between primary care and
specialized services. In Canada, family physicians provide a significant proportion of hospital
care. For example, in Qubec the general practitioners of some remote regions spend as much as
57% of their time in hospital activities (48). Is this an appropriate way to use the expertise of
family physicians? Does this not compromise the future of primary care?
At the present time each of these redefinitions appears to conform to a different paradigm and to
be taking place on the basis of the internal concerns of each profession. One is left with the
impression that each profession is more concerned about defining itself on its own terms rather
than in terms of the entire system and how it can complement other professions.
Critical logistics for our troops in primary care
New ways of organizing practices and services are currently being tried out, implemented or
deployed across Canada: Ontarios Family Health Networks immediately comes to mind, as does
Qubecs Family Medicine Groups, to name just two.
The desired changes in professional practices have largely been the result of new organizational
models. The implementation and deployment of these models often lead to a need for other
changes, particularly in specialized services. The changes therefore represent an absolute priority
for health systems over the coming years; this was the conclusion reached by the American
Association of Family Physicians after it completed an unprecedented strategic planning
initiative (51). It is nevertheless critical that these new models not be primarily intended as
responses to a strictly bureaucratic or administrative logic, but be implemented in a way that
fosters collaboration between professionals and makes their interventions work better together. It
is only by reinforcing this collaboration and complementarity that we will be able to ensure more
appropriate, more easily accessible and more continuous care.
New forums for exchange
Several respondents, both general practitioners and specialists, deplored the fact that the
migration of family physicians from hospitals had deprived the two professions of
opportunities for regular contact. We must create new points of contact and collaboration by
creating new opportunities for each profession to exchange knowledge and profit from each

39

others expertise and views. In clinical care, the shared care model that was developed in mental
health could be applied to other areas where the integration of primary care and specialized
services is crucial (56). Under this model, telephone consultations, community-based
consultations and professional development could become new forums for exchanging ideas and
sharing responsibilities. In structural terms, it is also necessary to create new places where
primary care and secondary services take joint responsibility for given clienteles. For example, an
ideal opportunity to implement this idea already exists in Qubec, where health services are being
reorganized into accessibility networks that are organized geographically by territory. The
networks bring together health care facilities and professional offices.
A better fit between training and the needs of practice
Although collaboration between the family physician and the specialist is recognized as an issue
in primary care reform, our survey has shown that very few residency training programs
explicitly recognize this objective. It is true that the programs we studied rewrote their learning
objectives because of CanMEDS 2000. However, few objectives have been drafted for specific
specialties. The objectives only integrate traditional concepts of collaboration, and only rarely do
they identify the specific type of collaboration sought.
Although the CanMEDS 2000 initiative clarified the functions of the medical specialist, if we are
not careful it may simply widen the pedagogical gulf that has slowly formed between residency
programs in family medicine and residency programs in the specialties. It can exacerbate the
perception that a common language is being lost and give the impression that there is a
fundamental difference between these two sub-groups of a same profession. This initiative also
enables family medicine to withdraw from and/or be left out of the pedagogical exercise that is
currently mobilizing specialty programs to examine competencies common to all types of
physicians. We think that this kind of exercise could lead to the creation of new forums for
residents who must, at one point, be split up in order to be exposed to clinical environments that
are more appropriate to the requirements of their future practice. This position appears all the
more difficult to defend when certain positions on the functions of family physicians have been
developed around the same functions as those given by CanMEDS 2000 (10).
Finally, our analysis of the interviews suggests that specialists are still giving medical students
very negative messages about careers in family medicine. This is a group whose initial training is
mainly in the hands of specialists working at university hospitals. Respondents also confirmed
the importance of role models in the process by which students learn collaboration between
family physicians and medical specialists: residents often have experiences that counter the
official view (and it is one that is very timid). Our findings also reveal how specialized training
programs and residency programs in family medicine are effectively isolated in silos.
Refuse the false dichotomy of the university hospital / community hospital
We believe that the search for training solutions slipped into a rut when it hit upon this
dichotomy: train specialists in university hospitals and train family physicians in communitybased hospitals. It is far from certain that this approach offers better training for family
physicians or medical specialists. On the other hand, one could conclude that this each to their
own approach has not significantly improved collaboration between the two groups.

40

We applaud the movement to create clerkship programs for specialists in community settings
(although the word community is often confused with remote). This movement to favour
community settings is driven by the political will of medical faculties, which want to fulfil their
responsibilities to the regions. On the other hand, we do not see a willingness to innovate in order
to meet the needs of urban communities. Considerations for the development of collaborative
practices do not lie behind these changes. The traditional models of practice are often reproduced
in new locations.
Social psychology has shown that one of the ways to eliminate prejudices and foster
collaboration between two groups is to give them the opportunity to acquire practical experience
by collaborating on a search for solutions to concrete problems (57), (58). It is therefore clear that
we need to provide family medicine residents and residents in the specialties with many joint
training activities and rotations in settings where they need to play their respective roles. These
activities should take place in the regions as often as they take place in urban areas. What we
need to avoid is the current situation, where the family medicine resident is often an
ersatz Resident I in a specialty, working in teaching units that are structured according to the
traditional hierarchy.
The problem of inappropriate training for family physicians is not entirely due to the setting in
which it is given. What concerns us here is the attitude and the approach of those who give the
training. This is therefore where the work needs to be done. For example, we should ensure that
more family physicians teach in our educational institutions or that there is more joint work
involving specialists and generalists.
Doing ones part in knowledge creation
In terms of formal scholarly activities, family medicine, as a health sciences discipline, is
certainly far behind specialist disciplines, but it also lags behind other disciplines such as nursing
and pharmacy. These last two groups have invested an enormous amount of energy into
consolidating the scientific basis of their professions. At the same time, their research supports
the legitimacy of their interventions by, for example, documenting efficacy.
Family medicine, as a discipline, would appear to have a difficult relationship with the idea of
research, which many practitioners perceive as being tainted with elitism. Even though there is
now a stream of family medicine literature that proposes a more precise construction of the
specificity of knowledge and research in family medicine (59), (60), (50), it must nevertheless be
acknowledged that this has not been a priority in either the academic community or in practice
settings. Even so, considering the importance of codified or academicized knowledge in the
dynamics of the professional system (25), (26), we should not minimize its importance as a
means by which family medicine can develop its professional work.

41

4. CONCLUSION
This study heard from family physicians and medical specialists reaching the end of their training
as well as certain individuals in charge of this training. It explored how young professionals
perceive their future roles in a health care system based on collaborative practice and how they
imagine their specific contribution to this new form of practice. More specifically in terms of
collaboration between family physicians and medical specialists, the study also sought to deepen
our understanding of how various residency programs implement and attain the training
objectives related to collaborative practice competencies.
Even though the study has been limited to exploring research questions through the views of
professionals in only four medical disciplines (family medicine, internal medicine, psychiatry and
radiology), it is the first Canadian study to have collected the views of such a large sample. It
joins an international corpus of similar studies from France (63), Belgium (61) and the United
Kingdom (62). Despite the different contexts, these studies demonstrate that our current problems
are universal in nature.
This study stands out for the analytical approach used: an application of the system theory of
professions developed primarily by Abbott (26) (following on the heels of work by Freidson
(25)). Few authors have applied this analytical framework to the study of how family medicine
and specialized medicine complement each other. Our respondents views confirm that a systemwide perspective is necessary in order to analyze and understand the phenomena they describe
and the issues they raise.
PRINCIPAL FINDINGS
What have we learned from this study? How have the findings improved our understanding of
collaboration between family physicians and medical specialists? What lines of thinking, action
and research have been introduced?
Four themes have emerged from our observations: the gulf between preferred and actual
practices, the identity crisis in family medicine, problems that are preventing collaboration
between family physicians and medical specialists, and the need to develop new models for
practice and teaching.
The gulf between preferred and actual practice. This issue was discussed by all our
respondents. Although our study has not broken any new ground in this area, it has nevertheless
confirmed the conclusions of the various surveys and studies mentioned in the introduction. On
the other hand, the analysis has enabled us to dig a bit deeper into this problem and dissect the
phenomenon of a gulf between preferred and actual practice, and we hope that our analysis has
provided a better understanding of the problem and will lead the way to better solutions.
Without going so far as to say there is a generation gap in family medicine, the interviews
reveal the existence of a conflict of values between family medicine residents and their educators.
This has created some discomfort on both sides of the issue. This break between the aspirations
and values of future family physicians and those of their educators was also noted by
42

investigators who carried out similar studies in France (63), Belgium (61) and England (62). We
know little of this phenomenon, but it merits our attention since it raises questions in ethics and
values as much as it does in professional education.
The interviews also revealed a gap between preferred and actual professional practices in
family medicine as well as in specialized medicine. Family medicine defends its position in the
professional system with a well-established ideology in which the accessibility, continuity and
comprehensiveness of care are presented as dominant values defining the discipline. The main
criticisms currently being made of the health care system focus on precisely these same issues, so
by taking these values as the foundations of its identity, family medicine finds itself in a position
of great vulnerability. Given the current environment, it is not surprising that the credibility of
family medicine has suffered in the eyes of specialists, not to speak of the general public.
Specialized medicine, which takes expertise as its fundamental identity value, has fared better,
but this could change if CanMEDS 2000 objectives are fulfilled. In fact, specialized medicine is
now expected to adopt an ideology that gives priority to other values, like collaboration and
professionalism. Specialized medicine is therefore setting up a situation where what it can
actually put into practice is sure to fall short of projected values, so the profession will soon be
challenged more than it has until this time. Indeed, given what specialist physicians working in
university hospitals told us about collaboration with family physicians, one could conclude that
as the value of collaboration receives more emphasis, academic specialists will appear more out
of touch with desired practice than their colleagues working in the field. Their legitimacy as
educators and, by extension, the legitimacy of family medicine training environments in
university hospitals, could become more and more contested. This issue was raised by the
Qubec College of Physicians in a position paper on family medicine (34).
Several observers have discussed the identity crisis in family medicine (32), (42), (54), (9).
Even though we identified several tensions within the profession (in particular, in young
physicians who hope to achieve a certain quality of life yet must confront the demands of
accessibility and continuity), it would appear that it is the conflict between scope of practice and
expertise that represents the Gordian knot of this identity crisis. The issue of expertise becomes
particularly critical when hospital practice is an integral part of the concept of the family
physicians scope of practice. Family physicians in Canada find themselves in a situation that is
the opposite of that experienced by European family physicians. In Europe the problems are
accessibility and availability, as the majority of general practitioners still work on their own, and
few are active in hospitals (61), (63), (64). And according to our analysis, family physicians
attachment to their relationship with patients appears to limit their ability to see collaborative
practice with other professionals as one of the solutions to the problem of attaining the desired
scope of practice.
Problems of collaboration between family physicians and medical specialists. Remarks
made by family physicians and medical specialists revealed ingrained prejudices on both sides. It
would appear that little progress has been made on this issue since the Royal College of
Physicians and Surgeons of Canada and the College of Family Physicians of Canada examined it
in 1993 (21). These prejudices are sustained in part by the perception that there is a significant
gap between the official view of each profession and the practices of its members, as well as
different perceptions of the roles and responsibilities of each group. Having less in common
places where both groups train or practise, a common language is a key problem that must be

43

addressed in any attempt to foster collaboration between family physicians and medical
specialists. Considering what has been lost, the temptation is to return to the place where
relationships of trust and closeness could very well develop: the hospital. One detects some
nostalgia in remarks made by both groups on this subject. Some respondents suggested that good
relationships could be rebuilt by bringing the family physician back to this lost paradise,
hospital practice.
New practice and training models
Respondents proposed several possible responses to these problems. They can be summarized in
the notion of creating new practice models, the fourth main theme of this study. Respondents saw
the need for system-wide change. We believe that the intuition of our interviewees is on the
mark: neither group by itself can deliver solutions to these problems or carry the responsibility of
making new models of practice a reality. This incapacity of either group to effect system changes
probably explains the feeling of powerlessness and the wait-and-see attitude registered in our
interviews.
COURSES OF ACTION, BUT ALSO FURTHER THOUGHT AND RESEARCH

Study participants joined investigators in proposing possible solutions that, for the most part,
complement ongoing reforms in our respective juridictions. However, the new practice models
(and eventually the new training models) beg some questions that can only be fully answered in
their implementation. Here again, the old saying still applies: the devil is in the details.
Even though it is easy to take a position in support of the family physicians scope of practice,
it must be clearly acknowledged that it will never be put into practice in the traditional manner.
One of the determining factors for this new scope of practice will be the role accorded to
general practitioners in hospitals. Human resources planning counts on the participation of
general practitioners in the delivery of specialized care. This pleases specialists who,
overwhelmed with work, would like to see general practitioners in their care units. It also suits
many family physicians. With the internist becoming increasingly rare, some have even
suggested that physicians trained in family medicine should assume the functions of hospitalists.
What role do we want the general practitioner to assume in hospitals? We believe that this is the
key question, the one that needs to be addressed first, since our answer will depend on the real
content of family physicians future scope of practice, even his or her future role. Unless the
system is amply staffed, we cannot think that family physicians will be everywhere and be able to
properly and effectively fulfil their assigned role. This is clearly not our current situation, since
the shortage of family physicians and nurses is having a domino effect that is being felt not only
in primary care but throughout the entire health care system. We therefore need to make some
choices, choices that the Qubec federation of general practitioners 2005 report on medical
staffing summarized as follows: if the governnment chooses to promote an organizational system
in which the hospitalization of patients is handled by general practitioners working full-time in
hospitals, we will need to re-examine medical staffing in order to ensure that the public has
access to primary care medical services (48). The report also states that the role of family
physicians in primary care needs to be clarified, a remark that is very relevant to this discussion
and that opens up a considerable number of research possibilities.

44

It is also easy to say that we need to develop new models for structuring interactions between
family physicians and medical specialists, models that would of course include their care teams.
Given phenomena such as rising rates of comorbidity and the increasing complexity of health
problems, the solution undoubtedly lies in more fluid relationships between primary care and
specialized services. A patient can no longer be considered a case for general medicine or a
case for specialized medicine. However, some studies have suggested that bringing a general
practitioner into specialized teams is not in itself sufficient to improve care (24). Family
physicians cannot assume their role and maintain their scope of practice if specialists are not
willing to reconsider their approach to practice, share more of their expertise, and share it
differently. In terms of the patients best interests, when should the specialized sector take
responsibility for care? When should specialized teams be satisfied with supporting the family
physician and primary care? Full answers to these questions will not emerge without rigorous
studies that provide solid clinical outcomes.
Family physicians must accept the idea that their privileged relationship with the patient will
need to be tailored to fit the new reality of interprofessional relationships. However, any changes
to this relationship must not lose sight of the fact that, as suggested in the research, patients
consider this relationship important. Models centered on care delivery in more formalized,
institutional settings are less effective at preserving the personal relationship between the
user/patient and the professional carrying responsibility for the majority of his or her care (65),
(66). It is therefore essential that professionals learn to work in teams, yet as responsibility is
handed off from one professional to another, we cannot afford to lose the patient in a bureaucratic
maze where no one takes responsibility or clinical considerations take a back seat to
organizational concerns.
Finally, our proposals include commencing a program of research into educational methods.
We also question the basis of current professional development methods. It seems quite clear that
professionals who will need to collaborate on a daily basis cannot be trained in silos, but many
questions remain as to when and how to teach collaboration. For example, to what extent does a
professional identity need to take form before collaboration can be introduced into the
curriculum? Clearly it will not be enough to just sit students down in the same classroom, yet we
must also acknowledge that our understanding of the pedagogical bases for learning
interprofessional collaboration is still quite limited (22).
Given the power wielded by role models in professional training, we will not be able to influence
collaborative practices simply by discussing theory in the classroom and in workshops, however
interactive the experience. In health care, professional training cannot be changed without
modifying the institutions throughout the network where professionals acquire their clinical
experience. Formidable forces maintain the inertia of our educational institutions. Is it realistic to
think that they can be changed? Among the medical specialists we interviewed, very few were
able to express clear and thoughtful opinions on the need for innovation in this area, particularly
as it concerned the needs of primary care. Rereading their comments, one is struck by how they
perceive this solution as excessively restrictive, inasmuch as it would require a thorough review
of their work methods. This is particularly true in the organization of hospital work, in
compensation, in the very hierarchical structure of teaching units and in certification criteria for
educational institutions. For their part, family physicians are under similar constraints.

45

Given how crucial it is to consider training environments as the preferred laboratories for change,
we strongly agree with the general feeling expressed by respondents: all parties and all
stakeholders need to be concerned with problems in how the system functions. The stakeholders
must therefore work together, and their actions must be coordinated and address all the main
areas of the system: professional, clinical, organizational and educational.

46

Table 1: Summary of Discussions on the Nature of Professional Collaboration and the


Issues It Raises
Generally speaking, respondents expressed similar ideas on what constitutes effective
collaboration.
Qualities of good collaboration:
- Good communication
- Mutual trust
- Relevance of the consultations (requests and responses)
- Availability/time: in particular, the ability to provide opinions over the phone in a timely manner
- Clear definition of responsibilities
- Empowerment of the family physician: place the family physician clearly in the loop with respect to
information on the patient
Issues raised in collaboration:
- Issues in the sharing of responsibility: being certain that your advice will be followed; responsibilities poorly
defined in the follow-up of anomalies unrelated to the reason for the consultation; lack of clarity concerning
the degree to which the family physician wants to be involved.
- Ethics and values issues: specialists perception that family physicians sometimes have different and lower
standards: for example, that they are more sensitive to economic arguments of effiency than specialists).
- Issue of underestimating the clinical competencies of family physicians: the impression that their training is
superficial.
- Issue of collaboration between teams in primary care and specialized services: in addition to the physicians,
the various professionals associated with the teams need to be brought on board.
The bases of collaboration:
- Sharing clinical experience in case management. Developing a sense of belonging to a clinical entity that is
responsible for a clientele or a given popultaion (an institution, a program, a region).
Pitfalls to be avoided:
- Not understanding the others role, expertise or conditions of practice.
- Prejudices: Psychiatrists pick and choose their cases. Family physicians want to offload their difficult
cases.
- Lack of trust
- Lack of time
- Compensation structure that does not allow payment for telephone consultations

47

Table 2: Mail Survey Results by Residency Program

Radiology
Participation
Present
Types of objectives
RCPSC or institutional (RC/I)
General or specific (G/S)
Description
Describes a terminal competency
or an intermediate objective (TC/IO)
Cross-disciplinary competencies
Medical expertise
Communication
Administration
Health promotion
Scholarship
Professionalism
Types of collaboration
Multidisciplinary team
Patient/family
Medical specialists
Family physicians
Health professionals
Other
Innovative collaboration concepts
Multidisciplinary/interdisciplinary
Delegation
Conflict resolution
Knowledge sharing
Constructive negotiations
Diversity
Collaborative care
Vulnerable patients
Regions
Traditional concepts of collaboration
Leader
Understand his or her own and others
roles
Multidisciplinary team/team facilitator
Respectful
Professional attitude

Internal Medicine
Participation
Present
Types of objectives
RCPSC or institutional (RC/I)
General or specific (G/S)
Description
Describes a terminal competency
or an intermediate objective (TC/IO)

9/16
8/16
I7
S5
TC 6
IO 1

Cross-disciplinary competencies
Medical expertise
Communication
Administration
Health promotion
Scholarship
Professionalism
Types of collaboration
Multidisciplinary team
Patient/family
Medical specialists
Family physicians
Health professionals
Other
Innovative collaboration concepts
Multidisciplinary/interdisciplinary
Delegation
Conflict resolution
Knowledge sharing
Constructive negotiations
Diversity
Collaborative care
Vulnerable patients
Regions
Professional attitude

6
5
5
2
2
4
4

2
5
3
1

48

13/16
13/16
I 9 RC 4
S6G7
CT 6
OI 7

7
11
8
3
2
11
4
3
4
7
2

1
1

Family Medicine

Psychiatry
Participation
Present
Types of objectives
RCPSC or institutional (RC/I)
General or specific (G/S)
Description
Describes a terminal competency
or an intermediate objective (TC/IO)
Cross-disciplinary competencies
Medical expertise
Communication
Administration
Health promotion
Scholarship
Professionalism
Types of collaboration
Multidisciplinary team
Patient/family
Medical specialists
Family physicians
Health professionals
Other
Innovative collaboration concepts
Multidisciplinary/interdisciplinary
Delegation
Conflict resolution
Knowledge sharing
Constructive negotiations
Diversity
Collaborative care
Vulnerable patients
Regions
Self-criticism/humility
Traditional concepts of collaboration
Leader
Understand his or her own and others
roles
Multidisciplinary team/team facilitator
Respectful
Professional attitude

Participation
Present
Types of objectives
RCPSC or institutional (RC/I)
General or specific (G/S)

9/16
9
I8
S5G
4

Description
Describes a terminal competency
or an intermediate objective (TC/IO)
Cross-disciplinary competencies
Medical expertise
Communication
Administration
Health promotion
Scholarship
Professionalism
Types of collaboration
Multidisciplinary team
Patient/family
Medical specialists
Family physicians
Health professionals
Other
Innovative collaboration concepts
Multidisciplinary/interdisciplinary
Delegation
Conflict resolution
Knowledge sharing
Constructive negotiations
Diversity
Collaborative care
Vulnerable patients
Regions
Self-criticism/humility

CT 5
OI 4
4
9
6
2
7
5
7
6
3
4
1

1
2
4

1
1
1

Responsability for Dx and Tx


Traditional concepts of collaboration
Leader
Understand his or her own and others
roles
Multidisciplinary team/team facilitator
Respectful
Professional attitude

3
4
5
5
1

49

10/16
10/16
I9
S7G3

CT 4
OI 6
5
4
6
2
1
1
5
5
6
1
5
2

1
2
1

1
4
1
1
2
7
4
2
1

REFERENCES
(1) Tyrell L, Dauphinee WD, on behalf of the Canadian Medical Forum Task Force. Task
Force on Physician Supply in Canada. Association of Canadian Medical Colleges, editor.
1999.
(2) College of Family Physicians of Canada.Primary Care and Family Medicine in Canada. A
Prescription for renewal. A Position Paper. Mississauga: 2000.
(3) Gouvernement du Qubec . Rapport et recommandations - Les solutions mergentes Commission d'tude sur les services de sant et les services sociaux. Gouvernement du
Qubec. 2000.
(4) Romanow R.J. Building on values. The future of health care in Canada. Ottawa:
Government of Canada, 2002.
(5) Starfield B, Lemke KW, Bernbardt T, Foldes SS, Forrest CB, Weiner J. Comorbidity:
Implicatons for the Importance of Primary Care in "Case" Management. Annals of Family
Medicine 2003; 1:8-14.
(6) Bodenheimer T, Wagner EH, Grumbach K. Improving Primary Care for Patients with
Chronic Illness.The Chronic Care Model, Part 2. JAMA 2002; 288(15):1909-1914.
(7) The Royal College of Physicians and Surgeons of Canada.Competencies for the new
millenium. Report of the Working Group on Societal Needs. CanMed 2000. Ottawa 1976.
(8) Dutil R. Loi 90 Complmentarit plutt que substitution. Le Mdecin du Qubec 2004;
39(2):11-12.
(9) Olesen F, Dickinson J, Hjortdahl P. General practice-time for a new definition. BMJ
2000; 320:354-355.
(10) Wonca Europe. The European definition of general practice / family / medicine. Wonca
Europe - Geneva 2002.
(11) WHO Regional Office for Europe. Framework for professional and administrative
development of General Practice/Family Medicine in Europe. Charter for General
Practice/Family Medicine in Europe. 1998.
(12) Future of Family Medicine Project Leadership Committee. The Future of Family
Medicine: A Collaborative Project of the Family Medicine Community. Annals of Family
Medicine 2004; 2:S3-S32.
(13) Rosser W. The decline of family medicine as a career choice. CMAJ 2002; 166(11):14191420.
(14) Watson DE, Katz A, Reid RJ, Bogdanovic B, Roos N, Heppner P. Family physician
workloads and access to care in Winnipeg: 1991 to 2001. CMAJ 2004; 171:339-342.

50

(15) Bates J, Andrew R. What do they contribute? Family medicine residents who practise in
cities. Can Fam Phys 2003; 49:337-341.
(16) Woodward C.A., Cohen M., Ferrier B., Brown J. Physicians certified in family medicine.
What are they doing 8 to 10 years later? Can Fam Physician 2001; 47:1404-1410.
(17) Savard I., Rodrigue J. Les premires annes de pratique des omnipraticiens : tude des
cohortes de 1989 1997. Le Mdecin du Qubec 1999; 34(2):105-114.
(18) Chan B.T.B. Do family physicians with emergency medicine certification actually
practise family medicine? CMAJ 2002; 167(8):869-870.
(19) Contandriopoulos A.-P, Fournier M-A, Dasssa C, Latour R, Perron M, Champagne F et
al. Profils de pratique des mdecins gnralistes du Qubec. Groupe de recherche
interdisciplinaire en sant. 2001. Rapport R01-10.
(20) Canadian Medical Association. The National Physician Survey & the future of medicine
in Canada. MD Pulse 2005. 1-64.
(21) The College of Family Physicians of Canada, The Royal College of Physicians and
Surgeons of Canada. The Relationship between Family Physicians and
Specialist/Consultants in the Provision of Patient Care. The College of Family Physicians
of Canada; the Royal College of Physicians and Surgeons of Canada 1993.
(22) Oandasan I, D'Amour D, Zwarenstein M, Barker K, Purden M, Beaulieu MD et al.
Interdisciplinary Education For Collaborative, Patient-Centred Practice. Health Canada,
February 2004, 304 pages.
(23) Lo E, Rezai K, Evans AT, Madariaga MG, Philips M., Brobbey W. et al. Why Don't They
Listen? Adherence to Recommendations of Infectious Disease Consultations. Clinical
Infectious Diseases 2004; 38:1212-1218.
(24) Mitchell G, Del Mar C, Francis D. Does primary medical practitioner involvement with a
specialist team improve patient outcomes? A systematic review. Brit J Gen Pract
2002;(934):939.
(25) Freidson E. Professionalism The Third Logic. On the practice of knowledge. The
University of Chicago Press. 2001.
(26) Abbott A. The System of Professions - An Essay on the Division of Expert Labor. The
University of Chicago Press 1988.
(27) The College of Family Physicians of Canada.Four principles of Family Medicine.
Electronic citation.. http://www.cfpc.ca/french/clpc/aboutus/principles (dernire mise
jour 2002)
(28) Societal Needs Working Group. Skills for the New Millennium. Annals CRMCC 1996;
29:206-216.
51

(29) Shapiro M. Getting Doctored. Critical reflections on becoming a physician.Between the


lines. Kitchener (On):1978.
(30) Stelling JG. Becoming Professional. Sage Publications. London: 1977.
(31) San Martin-Rodriguez L, Beaulieu MD, D'Amour D, Ferrada-Videla M. The determinants
of successful collaboration: A review of theoretical and empirical studies. Journal of
Interprofessional Care 2005; Supplement 1:132-147.
(32) Sox H.C. The Future of Primary Care. Annals of Internal Medicine 2003; 138:230-234.
(33) Task Force to Review Fundamental Issues in Specialty Education. Fundamental Issues in
Specialty Education. Annals CRMCC 1996; 29:272-277.
(34) College des mdecins du Qubec. Le mdecin de famille : un rle essentiel moderniser.
Collge des mdecins du Qubec, 2005, 1-11.
(35) Moore G., Showstack J. Primary Care Medicine in Crisis: Toward Reconstruction and
Renewal. Annals of Internal Medicine 2003; 138:244-248.
(36) Whitcomb ME, Cohen JJ. The future of primary care medicine. N Engl J Med 2004;
351:710-712.
(37) Collge des mdecins du Qubec. Nouveaux dfis professionnels pour le mdecin des
annes 2000. Collge des mdecins du Qubec ed. 1998.
(38) Cohen M., Ferrier B., Woodward C.A., Brown J. Health care system reform. Ontario
family physicians' reactions. Can Fam Physician 2001; 47:1777-1784.
(39) Savard I, Gaucher S, Rodrigue J, Dub R, Villeneuve P. Les mdecins de famille de
nouveau sous la loupe. Le Mdecin du Qubec 2005; 40:105-116.
(40) Marshall MN, Mannion R, Nelson E, Davies HT. Managing change in the culture of
general practice: qualitative case studies in primary care trusts. BMJ 2003; 327:599-602.
(41) Sandy LG, Schroeder SA. Primary Care in a New Era: Disillusion and Dissolution?
Annals of Internal Medicine 2003; 138:262-268.
(42) Showstack J, Anderson Rothman A, Hassmiller S. Primary Care at a Crossroads. Annals
of Internal Medicine 2003; 138:242-244.
(43) Harrold L.R, Field T.S, Gurwitz JH, Knowledge, Patterns of Care, and Outcomes of Care
for Generalists and Specialists. J Gen Intern Med 1999; 14:499-511.
(44) Frances CD, Shlipak MG, Noguchi H, Heidenreich PA, McClellan M. Does Physician
Specialty Affect the Survival of Elderly Patients with Myocardial Infarction? Health
Services Research 2000; 35(5):1093-1116.

52

(45) Cleland JGF. Patients with treatable malignant diseases - including heart failure - are
entitled to specialist care. CMAJ 172 2005; 2(207):209.
(46) Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai W, Cleary PD et al. Primary Care
Outcomes in Patients Treated by Nurse Practitioners or Physicians. JAMA 2000; 283:5968.
(47) Horrocks S, Anderson E, Salibury C. Systematic review of whether nurse pratitioners
working in primary care can provide equivalent care to doctors. BMJ 2002; 324:819-823.
(48) Savard I., Rodrigue J. Des omnipraticiens la grandeur du Qubec : volution des
effectifs et des profils de pratique - dition 2005. Direction de la planification et de la
rgionalisation, Fdration des mdecins omnipraticiens du Qubec. 1-29. 2005.
(49) Stange KC, Jaen CR, Flocke S, Miller WL, Crabtree BF, Zyzanski SJ. The Value of a
Family Physician. The Journal of Family Practice 1998; 46:363-368.
(50) Olesen F. A framework for clinical general practice and for research and teaching in the
discipline. Fam Pract 2003; 20(3):318-323.
(51) Graham R, Bagley B, Kilo CM, Spann SJ, Bogdewic SP. Report of the Task Force on
Patient Expectations, Core Values, Reintegration, and the New Model of Family
Medicine. Annals of Family Medicine 2004; 2:S33-S55.
(52) Wachter RM. Hospitalists in the United-States: Mission Accomplished or Work in
Progress? New Engl J Med 2004; 350(19):1935-1936.
(53) Freeman GK, Olesen F, Hjortdahl P. Continuity of care: an essential element of modern
general practice? Fam Pract 2003; 20(6):623-627.
(54) Gutkin C. Family practice subspecialists. Can Fam Physician 2004; 50:1175-1176.
(55) Health I, Evans P. The specialist of the discipline of general practice. BMJ 2000;
320:326-327.
(56) Rockman P, Salach L, Gotlib D, Cord M, Turner T. Shared Mental Health Care: Model
for Supporting and Mentoring Family Physicians. Can Fam Physician 2004; 50:397-402.
(57) Moscovici S. Psychologie sociale. 3 ed. Les presses universitaires de France, Paris1990.
(58) Berkowitz L. Advances in Experimental Social Psychology. New York Academic Press,
1980.
(59) The Lancet. Is primary-care research a lost cause? Lancet 2003; 361(9362):1-2.
(60) Green LA. The Research Domain of Family Medicine. Annals of Family Medicine 2004;
2(2):S23-S29.

53

(61) Dilige D. Des mdecins Belges parlent de leur mtier. Cahier Socio Dmo Md 2004;
44(4):443-506.
(62) Rowsell R, Morgan M, Sarangi J. General practitioner registrars' views about a career in
general practice. Br J Gen Pract 1995; 45:601-604.
(63) Levasseur G, Schweyer FX. Profil et devenir des jeunes mdecins gnralistes en
Bretagne. Union rgionale des caisse d'assurance maladie 2005; 22:1-20.
(64) Feron JM, Cerexhe F, Pestiaux D, Roland M, Giet D, Montrieux C et al. GP's working in
solo practice: obstacles and motivations for working in a group? A qualitative study. Fam
Pract 2003; 20:167-172.
(65) Lamarche P, Beaulieu MD, Pineault R , Contandriopoulos A.-P., Denis JL, Haggerty
J.Choices for Change: The Path for Restructuring Primary Healthcare Services in Canada.
Canadian Health Services Research Foundation. Ottawa: 2003.
(66) Safran D.G. Defining the Future of Primary Care: What Can we Learn from Patients?
Annals of Internal Medicine 2003; 138:248-255.

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