Tuesday, May 23, 2017

A Dangerous Idea: A "General" Medical Licence

Because I can't afford to attend the Family Medicine Forum on a Coroner/househusband/author's salary.

The Family Medicine Forum (FMF) is the largest academic Family Medicine conference in Canada. Each November, thousands of doctors, residents, medical students, teachers, and researchers descend upon one of Canada's major cities - the conference location rotates - to network, socialize, catch up with colleagues and learn. It can also be a real hoot, allowing one to mix-and-match ordinary refresher sessions with offbeat stuff in Medical Humanities and so on.

One of the more fun sessions at FMF is the annual "Dangerous Ideas Soapbox". The Soapbox is a chance for conference attendees to stand in front of a crowd and pitch a radical idea to a willing audience. The idea can be just about anything pertaining to Family Practice. The audience votes on its favorite idea, and, well, something happens. Slowly. Or doesn't.

Since signing off on blog posts and dead bodies isn't terribly lucrative, I won't be making it to FMF this year. But, since my thoughts on the uncertain future of Family Medicine have been fodder for lively Twitter debate, I'm going to go one step further, and present my very own Dangerous Idea:

A new, "general" category of licence to practice medicine.

A bit of history: once upon a time, Canadian doctors were eligible for independent licensure after a rotating year of internship. A doctor could go on for a second year of Family Medicine residency and obtain certification from the College of Family Physicians (CFPC), enter a specialty residency, or go out and practice independently.

In the mid-1980s, the profession had a heated internal debate over how much and what sort of training was needed to practice medicine independently. The conclusion was: two years, with a curriculum and exam administered by the CFPC. By the early 90s, all provinces had phased out the one-year path to practice, though not without causing genuine tumult in the transition.

The "new order" meant that a doctor's chosen field of practice was selected while still in medical school. There was a bit of wiggle room to switch programs while in residency, but once a doctor had been out in practice, re-entry into a specialty could only happen with some sort of return-of-service agreement, if at all. For all this new setup would do to empower the CFPC and bring a (hopefully) renewed vigor to Family Medicine, even the task force foresaw problems down the road:
It requires little imagination to extrapolate the present trend to a day when family physicians find themselves withdrawn into their offices, beleaguered on the one hand by well-trained specialists willing to expand from consulting into specialized primary care and on the other hand by growing numbers of nonmedical counsellors increasingly successful at convincing the public that medical training is superfluous to providers of social advice. We believe this will be a sad day for patients; it will be a disaster for family physicians.
Specialists didn't move into primary care, but Nurse Practitioners and other health professionals have been flexing their muscles for some time now. When you couple that with what the task force didn't foresee - namely, family doctors not practicing family medicine - it would be hard to interpret the falling interest in Family Medicine as anything but the start of a return to the dark days of the late 90s and early 2000s, when up to 3/4 of medical students said no thanks.

Shifting the culture in medicine, or re-examining who should get into med school, will take years-to-generations, if it's even possible. Still, we have chronic shortages in rural areas, and a new phenomenon of specialists unable to find work. It's too little, too late for the current job hunters, but there is a way to help both these problems, and in all likelihood improve the attractiveness of Family Medicine: a new "general" category of medical licence, earned after a mandatory two years of residency, that still allows doctors to enter the residency match for specialties or sit the CFPC exam.

A new (or restored, if you prefer) general licence doesn't mean a doctor should be allowed to practice Family Medicine independently without sitting the CFPC exam. Such a doctor, could, however, cover brief locums, staff a university or sexual health clinic, work as a hospitalist, work with nursing homes, and so on. This kind of work should be paid at a discount, or on a return-of-service basis, as an incentive for someone enjoying general practice to become a full-fledged Family Doctor. Regardless of pay, a general independent licence would give much needed flexibility to recent grads that aren't sure what they want to do, let young doctors take parental leave without the stresses of getting their own practices covered, and help put out rural staffing fires. And it's a guarantee that experience in general practice will raise the beleaguered profile of Family Doctors in the eyes of their specialist colleagues.

A general licence option might even improve upon the popularity of Family Medicine, as new doctors would have time to get a feel for what they do and don't like, without the pressure of having to limit their options while still in medical school. Moreover, such a regime could help recruitment in fields that medical students often dismiss - Public Health, Psychiatry, Pathology - but older docs might take a second look at once they've been working a few years.

I'm not blind to the obvious criticism: where do the patients and taxpayers get a say in this? This is a doctor-centric solution that ignores the real needs of communities. What does it do to a community when young doctors come and go as they please? What about the long-term doctor-patient relationship in Family Medicine?

To which I respond: what's the alternative? The majority of young and future doctors either aren't interested in the job, or at a minimum aren't interested in the commitment. Until you can change the culture and practice patterns of doctors naturally - which might not happen at all - the alternative is forcing doctors' hands: "you will work within these models where you're needed, or you will not work".

Is that really what Canadians want in their doctors? A limited sense of autonomy and control, in the name of serving some public (or is it political?) purpose that flies in the face of the absolute excellence we demand from would-be doctors? The system as currently designed puts the financial risks of practice in the hands of the doctor. You're going to tell a young doctor where and how to practice and make her pay the overhead? How easy will it be to get people into Family Medicine under those conditions? And what happens when one town or province stops forcing the issue in the name of recruitment, or offers incentives such as free rent?

The general category of licence: a dangerous idea whose time has come.

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