You're a family doctor and you've
been practising medicine in small town Canada for over
20 years. You see thousands of patients a year, you pull
in an extra ER shift here and there to help out your local
colleagues. But you're getting tired. You're thinking
it might be time to move on to something new, something
that requires you to see fewer patients. It's time to
slow down. You turn to the classifieds but find that you
aren't qualified for any of the jobs. The reason? You
don't have your CCFP.
So what do you do? You study
like crazy, cramming between patients and get yourself
ready for the exam. You're confident. After all, you've
been practising for over 20 years. You know what you're
doing. Or at least that's what you think.
COMMUNICATION BREAKDOWN
The CCFP examiners might have some different ideas about
your skill set. Just ask Dr Barbara Watts, a 49-year-old
physician from Orangeville, ON. She's been there. She
decided to get her CCFP in 2002 to improve her salaried
job prospects. When she got her exam results she was
shocked to learn she'd been failed on the oral portion.
"What they said to me was that I'm out of touch with
current medical thinking," she recalls. "And the fact
that I failed was my fault."
But how could a GP with that
much experience fail a competency exam? "There are a
lot of different explanations for why a practice-eligible
doctor fails the exam," says Paul Rainsberry, PhD, director
of education at the College of Family Physicians of
Canada (CFPC). The college's education committee comes
up with the test material and it's administered by past
CCFP 'certificants.' According to Dr Rainsberry, a little
over 10% don't make the grade.
Dr Watts says it all came
down to four little words: patient-centred clinical
method. Her interview skills were out of step with what's
being taught in med schools now, she was told. And she
feels she was punished for having trained when she did.
She also says it was difficult to find out how this
gap in her knowledge could be filled. "I see that they're
setting us up to fail," she says, "they're not offering
a course that we do need."
Dr Rainsberry admits that
there's little out there in terms of CME that addresses
doctor-patient communication skills. He says that's
primarily due to the fact that pharma companies -- who
sponsor most CME events -- have little interest in the
issue.
Whatever the reason, this
lack of comprehensive continuing education conspires
to prevent older GPs from keeping up with evolutions
in communication methods. "Older doctors were trained
to focus on the disease," explains Kathy Smith, PhD,
an associate trainer at the University of Toronto's
patient-centred clinical method workshop. "They have
worked through a model that is a lot more doctor-oriented."
Nowadays, med students are trained to put the patient
first. Hence the patient-centred method.
MY KINGDOM FOR A COURSE
The concept is far from new. It was developed by Dr
Moira Stewart and colleagues at the University of Western
Ontario back in the 80s. They described the method in
a series of articles in Family Practice in 1986,
writing that the method "is designed to attain an understanding
of the patient as well as his disease."
The three major points of
the method are: 1) exploring both the disease and the
patient's illness experience; 2) understanding the whole
person; and 3) finding common ground. It's since been
widely adopted and is now viewed as standard practice
in family medicine.
But it's not all been smooth
sailing. There are a few catches. First, Canadian med
schools didn't start teaching the method until after
1993. So doctors who graduated before that have had
to either read up on the method themselves or seek out
an intensive -- and costly -- workshop to help them
perfect their skills. Which brings us to catch number
two: such courses are only available in Toronto, at
U of T. Lastly, if practice-eligible doctors are looking
to get their CCFP certification, they need to know patient-centred
clinical method. And there's the rub.
GENERATION GAP
A big problem is that the method essentially conflicts
with the way older doctors were taught to practise medicine.
"With the older method the patient comes in with an
illness and you treat the illness," explains Dr Motunrayo
Adetola, an MD originally from Nigeria who now practises
in Brookfield, NL. "But this newer method teaches you
to treat the patient." He took the intensive workshop
at U of T and says he's glad he did. The patient-centred
clinical method helps him connect with the patient's
world, making it easier to treat them as an individual.
He passed the exams and now has those precious letters,
CCFP, after his name.
The sort of bridge-building
Dr Adetola was taught requires a pretty hefty time investment.
But the reality is we're in the middle of a doctor shortage
and most doctors simply don't have that kind of time.
"I'm out here in the real world," says Dr Watts, "where
there are far too many patients to see. I don't have
time to do a 15-minute interview. None of us can do
that."
After locking horns with
the college over her certification, Dr Watts decided
to let sleeping dogs lie. "I now call myself a GP and
not a family doctor," she says. "I feel that the college
has said that I'm not good enough." Not having her CCFP
has limited her job prospects, but she has the reward
of being a respected physician in her community.
What do you think? Email
us at [email protected]
or fax us at 514-397-0228.
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