Goverment & Medicine

Wanted: Renaissance persons, MD

Are family doctors about to become an endangered species?

By Susan Usher

Like earth to the Ptolemaic planetary system, at the gravitational centre of every healthcare reform effort is a weighty and powerful figure: the general practitioner.

A team leader in community health centres, a lone pioneer in remote areas, a tech wizard in telemedicine, capable of managing most any health concern that walks through the door, the GP has been placed at the centre of what policymakers imagine as the health system of the future.

The only problem is, there aren't enough of them and hopes of churning out more are being dashed before graduation day at medical schools across the country. The Ontario government became so concerned this past year that they turned to Dr Michael Green, Assistant Professor in the Department of Family Medicine at Queen's University to look into what measures could be taken to up the number of med students opting to be FPs.

GET 'EM WHEN THEY'RE YOUNG
"We were asked to review the literature to help the Ministry move ahead in discussing what they could do with other partners," says Dr Green. "We focused on admission policies and processes that would result in more or less students going into family medicine. What are the questions, what are your admission criteria, what matters when people come in."

Dr Green cites American research that shows family doctors to be more people-oriented and less technically-oriented, more likely to be older and female, less likely to have doctors as parents, and less concerned with income and prestige. "One study from the US shows that those with very high MCAT scores, as opposed to very good but not the best MCATs, are more oriented towards specialized medicine. It reflects how much of their time they invest in studying detail," he says. Asking med students at the outset whether they would consider a career in family practice is another way to predict their eventual choice. Dr Green found that people come into med school with a value set reflecting what they're interested in, and that in this way, family doctors differ greatly from specialists. "It's a matter of making sure that you have enough people in medical school who are interested in family practice to make the mix that you want," he says.

STRAIGHT TO THE TOP
Deans of medicine also hold great sway over the path a bright-eyed bushy-tailed young med student will take. The government distributed the report to deans and associate deans at the medical schools in Ontario and to the Council of the Ontario Faculties of Medicine, nudging them to look into some of the recommendations for medical schools and academic health sciences centres.

"The deans are still discussing it," says Dr Green. There's agreement on some points, but he sees resistance to what's perceived as interference from government in ivory tower issues. "The medical schools see their position as the experts in education and want to have control over this domain," he says. The government wants more power to influence the look of the healthcare system.

Med students' choices are also influenced by the amount of time in rotations devoted to family medicine and the number and distribution of residency training positions in family practice. Here the medical schools acknowledge a service role, Dr Green believes, "so there's at least a desire to come to some sort of agreement with the government."

MATURE APPROACH
Dr Gilles Hudon, Director of Continuing Professional Development and Health Policy at the F�d�ration des M�decins Sp�cialistes du Qu�bec and a cardiologist, thinks confidence has a lot to do with the choice. "I would not have been able to be family physician at 30 years old," he says, "though I could today. It takes more maturity because FPs are expected to treat not just a medical problem, but a whole person."

He also believes the role of FPs will be increasingly difficult to fulfill. "These doctors will become specialists in general medicine, whether we like it or not," he predicts. "We cannot take five years to train someone on a specialized but limited subject, and only two years to cover a broad area at a more superficial level."

GPs face greater expectations and get more recognition than they did 20 years ago, Dr Hudon believes, but these expectations must be matched by more supportive relationships within medicine, adding "the greatest incentive to go into family medicine will be the support they know they can get from the care team around them and the specialists."