Decline of family medicine

In the last few weeks a number of patients that I have seen in my office have expressed frustration and concern because they have not been able to find a family physician, and on one occasion I was asked if I would undertake the role (very flattering, but after 17 years as a specialist, I’d have to go back to medical school!). The recruitment and retention of family physicians has been an increasing problem over the past few years, particularly in rural areas, but is now recognized as a global problem. Family practice as we knew it seems to be a dying field.

According to recent statistics, of this year’s medical school graduates only 24% are choosing FP as their first residency choice. Of those who do, many work in walk-in clinics rather than as full-service FPs. In the 1 April issue of the CMAJ, a news article stated that after the first round of the 2003 residency match, 139 of 484 training positions in family medicine—29%—remain unfilled, with one-third of the 36 programs filling 50% or less of their openings.

There have been many reasons cited for the significant decline in interest in FP as a specialty. One of these is the view that it is less prestigious than other specialties, and I think this is partially true, particularly in this area of advanced technology and consumer expectation—the expectation that everyone should see a subspecialist.

But I think that a more fundamental reason is the perception that FP is undervalued and the role is slowly eroding.

I am fortunate to work in a community with a large number of dedicated full-service FPs. They work long hours and manage the complex cases not dealt with in the walk-in clinics. Until recently, a large percentage provided full on-call hospital coverage and were actively involved in all aspects of care. The BCMA negotiations with government addressed specialist on-call payment and now MOCAP compensates specialists but provides no compensation for full-service FPs (in urban areas) and only a small amount for doctor-of-the-day coverage. Consequently, and I feel justifiably, many of them have relinquished hospital privileges. I strongly believe that in the long run this will have a detrimental effect on the provision of quality medical care.

FPs play an integral role in the care of patients and their families and I would find my job difficult, if not impossible, if a FP was not part of the team. As specialists we focus on our own area of interest and expertise, and particularly in urban centres where there are often multiple specialists involved, the continuity of care can be compromised without the invaluable input of the FP.

Should this be of concern to us as a profession? In my view, absolutely. Although many articles have been written about the decline of family medicine, I feel it is a critically important issue and should be the subject of ongoing discussion. We should take heed from the experience in the US. Nurse practitioners have assumed a larger role, providing care at a much lower cost, but despite this it has been recognized that FPs provide special skills that are irreplaceable, hence the intense efforts now to recruit traditional family doctors, who are well reimbursed for their services. If we were to compensate our full-service FPs adequately, I think it possible we would see a change in the current trend.

—SEH