The Modern Family Physician V The Old GP.

   I was an enthusiastic supporter of the College of Family Physicians from its (and my) early days.  Its greatest contribution was in the early concepts of  appropriate training for general practitioners.   Until then, there was the rotating internship, an entirely inadequate and exclusively hospital experience that provided virtually no training for the care of the ambulatory patients that make up the great majority of a general practice.  So the idea was to devise a training program that would enable a physician to look after the majority of patients that a community based physician would encounter.  The need for the well trained generalist was increasing as specialization grew into sub-specialization and as those sub-specialists got to  know more and more about less and less.   General internists became fewer and many of the issues they looked after became the responsibility of the GP by default.  General Practitioners no longer wanted to be considered 'only  a GP' and felt their field was a specialty  in its own right.  Emphasis was to be placed on  the whole person  and  not just on the disease.  That implied focusing on the whole family and considering the myriad influences that impacted on a patients physical and mental health. Our specialty was going to be broad and recognize where our expertise ended and colleagues needed to be called in to resolve the problem.  We decided that Family Practice was a more appropriate description of our role, because we felt it more clearly described where our focus lay and  our limitations.  Since there was no epistomology in Family Medicine, the four principles were detailed to more clearly define our role.  Clinical competence, continuity of care, comprehensive care, community care were and are the four pillars.  Things have changed since then and the pillars and principles have not.  They need to be carefully reviewed in view of the major changes that have occurred in the health care system and in society in general. On a few occasions I have suggested a study forum or to present a paper at the annual College meeting to review those pillars. I never received a reply.
  In particular, the certificates of added competence that the CFPC adds from time to time would seem to fly in the face of a specialty emphasizing the importance of generalist skills.  We seem to be repeating history in splitting off  of 'mini' or second class specialists, from the main nucleus of Family Physicians.  I do recognize that certain circumstances of practice require additional training, but is this the way to achieve it?  This is what we have so far:

Designation

Care of the Elderly CCFP(COE)/MCFP(COE)

Palliative Care CCFP(PC)/MCFP(PC)

Family Practice Anesthesia CCFP(FPA)/MCFP(FPA)

Sport and Exercise Medicine CCFP(SEM)/MCFP(SEM)

Emergency Medicine CCFP(EM) /MCFP(EM

This could go on for ever.

   My question, how far is the College prepared to go in certifying mini-specialists?  Is that activity in line with the avowed aims of Family Medicine or is it just starting the whole fragmentation of medical care all over again.  This homeopathic approach of small doses of specialization seems to fly in the face of comprehensive, continuing care and has nurtured walk-in clinics, hospitalists and a growing variety of mini-specialists, all of whom may be very necessary, but have little to do family medicine and even less to do with continuity and comprehensiveness.  It seems that family physicians are doing less and less of more and more and that many of the tradition skills of general practitioners are atrophying.  This is the result of numerous influences, not least of which is the fee schedule and the philosophical underpinnings of the health care industry.
    Maybe it's time to devise a certificate of special competence in general practice? 

CAC Credential in
  Designation
Care of the Elderly CCFP(COE)/MCFP(COE)Palliative Care CCFP(PC)/MCFP(PC)Family Practice Anesthesia CCFP(FPA)/MCFP(FPA)Sport and Exercise Medicine CCFP(SEM)/MCFP(SEM)Emergency Medicine CCFP(EM) /MCFP(EM) - See more at: http://www.cfpc.ca/ProjectAssets/Templates/Category.aspx?id=7164&terms=certificate+of+competence#sthash.cnaTEIEO.dpuf

Care of the Elderly

Palliative Care

Emergency Medicine

Family Practice Anesthesia

Sport and Exercise Medicine

- See more at: http://www.cfpc.ca/ProjectAssets/Templates/Category.aspx?id=7164&terms=certificate+of+competence#sthash.cnaTEIEO.dpuf