BCMJ, Vol. 44, No. 9, November 2002, page(s) 491-492—Premise
Robert F. Woollard, MD, CCFP, FCFP
Change is in life cycle, not lifestyle
In his response to Dr Macgregor, the head of UBC’s Department of Family Practice says that changing patient demographics and expectations, inadequate resources, perverse payment incentives, and persistent political fractiousness all contribute to the current crisis.
Dr A.J. Macgregor’s letter represents un cri de coeur by someone I know to be a thoughtful exemplar of all that is best in the discipline of family medicine. As such it behooves us all to take notice of the situation as he describes it and, from our varying perspectives, seek to address the issues he raises. The slide that he describes away from full-service practice and even from the discipline of family medicine is long-standing and multifactorial. While complex problems require complex solutions, Dr Macgregor points out several salient features that provide both deep concern and the seeds of hope. The cardinal elements of both existing challenges and their possible solutions consist of the number and nature of practitioners, their lifelong education, the needs and expectations of their patients, and the resources and systems within which doctors and patients work together to address those needs and expectations. Each of these elements provides its own accomplishments and frustrations, its own joys and sorrows. However, Dr Macgregor appears accurate in assessing that the cumulative impact is an increasingly demoralized discipline increasingly unwilling or unable to provide the comprehensive, continuing, and accessible care to which we all aspire.
I would urge caution in ascribing too much emphasis on the differences between younger and older physicians under the rubric of lifestyle. One suspects that this may be as much an issue of the life cycle of physicians, the fact that medical school classes are older than they once were, that society as a whole (including older physicians) seems less inclined to defer personal and family development in service to the welfare of others. That more of our students and trainees are also parents and/or family members, is probably a healthy sign if we assume that over their lifetime they will provide dedicated service to their patients without burning out and moving into restricted areas delivering episodic care.
It is this lifelong dedication to professionalism and service that is the nub of the “practitioner” element in this complex equation. Changing expectations and demographics of the population, inadequate or unavailable resources, perverse and inequitable payment incentives, and persistent frustrating fractiousness at the political level all make serious contributions to the present crisis of confidence. All are worthy of attention and cry out for effective leadership.
Dr Macgregor alludes to these and enjoins us to seek pluralistic solutions rather than single models of care delivery. This is wise advice, which appears to be being heeded as the profession, the government, and their communities embark more formally on primary care renewal, in part through the Primary Health Care Transition Funds (PHCTF). While success is far from assured, it may be worth reflecting on the aspects of professional commitment to which Dr Macgregor alludes in his letter. It is clear that the health care system and its patients will be reasonably well served if there are increasing opportunities for physicians to organize their practices, partnerships, and relationships in ways that provide both effective patient care and the enduring professional satisfaction. This can be undertaken with effective systems of evaluation and educational support and the cooperative effort to decrease the barriers to the delivery of “continuous, comprehensive, competent, and caring” medical practice. However, such opportunities must be balanced with a renewed dedication on the part of the profession. Why should society create opportunities denied the majority of citizens if they cannot be assured of our unambiguous dedication to the welfare of patients? If we are willing to tolerate a norm of unavailability, contingent commitment, and grudging service, we need to be brutal with ourselves and with our peers and ask whether it is appropriate that we earn incomes that allow us to work half-time with limited ongoing responsibility and still earn more than other dedicated full-time workers.
I recently had the privilege of greeting the new medical student class and working regularly with more senior students and residents. I am as impressed with their idealism as I am with the evolving cynicism of any of their senior colleagues. Dr Macgregor’s letter exhorts us to find ways to nurture rather than denature that idealism. We should heed his wise counsel because a society that rewards its cynics while making its idealists feel like fools is sowing the seeds of its own destruction.
Robert F. Woollard, MD, CCFP, FCFP
Dr Woollard is the head of the Department of Family Practice, Faculty of Medicine, University of British Columbia.
