Time, Change and Family Practice
Reproduced with Permission from Canadian Family Physician
The two reports by Woodward and her colleagues in this issue raise important questions about the future of family practice. Changing attitudes to life and work are clearly demonstrated in the trends between 1993 and 1999 in the same cohort of family physicians. The hours worked per week decreased slightly for all physicians, both male and female. Preferred hours of work in 1999 were 37.2 for males and 31.0 for females. Preferences for hours worked and satisfaction with the balance between work and home life were important in predicting the hours worked. Those who were satisfied with the balance in both 1993 and 1999 worked 35 hours a week in 1993 and 33 hours in 1999. Those who felt the balance was not good at either time were working 48 hours in 1993 and 47 hours in 1999. Physicians without children, and women having a physician as spouse, or having a child under six, worked fewer hours. Women with all children at school worked longer hours.
We do not know what part economic factors played in physicians’ decisions about working hours. Physicians with debts to pay off, and children to support and educate, may not be in a position to reduce their hours, however much they wish to do so. Lower income needs may explain why females with physician spouses, and physicians without children, worked fewer hours. The higher debt loads for physicians graduating today, and higher tuition fees in the future for their children, could increase the gap between hours worked and hours preferred.
There are two ways of interpreting this trend towards a shorter working week. We could see it as a withdrawal from commitment, a wish to have one’s life and work in watertight compartments, a view of medicine as just another job, rather than a vocation . On the other hand we could see it as taking our role as healers seriously, making time for our own inner lives, trying to achieve a balance between an active and a more contemplative life. One of the two services that significantly increased between 199 3 and 1999 was counseling. Considering the complexity of so many of the health problems in family practice – chronic pain, occupational traumas and stresses, the so-called somatoform disorders, family dysfunction, anxiety/depression and so on – this is encouraging, especially if it signifies more time with patients and improving counseling skills. Counseling can be shared with nurses, social workers, and other more specialized counselors. But in the assessment and therapy of complex disorders, counseling skills are clinical skills. It is also significant that the great majority in both surveys offered psychotherapy. We do not know what form this takes, but it does suggest that the respondents regard it as important to family practice. There will be some that do not welcome this trend. I urge them to think again. Of all fields of medicine, family practice can show medicine how to transcend the artificial division between mind and body, which runs through medicine like a fault line. It is the kind of relationship we have with patients that distinguishes us more than anything else, and "psychotherapy" may be another word for the emotional intelligence we need in our relationships and our clinical judgements.
There are two ways to reduce one’s working hours. One is to reduce the services offered to patients; the other is to offer the same service to a smaller number of patients. To avoid confusion it is important to make a clear distinction between two different categories of service. Services such as home visits, hospital and nursing home visits, full or shared obstetric care, and a responsible 24 hour on-call deputizing system, are those we offer to the patients of our own practice. Shift work in an emergency department, anesthetic lists, industrial medicine sessions, and work in a sports medicine or cancer clinic are services for a very different population. If we happen to see one of our patients during one of these activities, it is coincidental. In an urban area it is unlikely. Services in the second category are important contributions to our communities, and some are essential in rural areas. But it is an error to use them as universal criteria of comprehensiveness.
Using the first set of criteria, the two surveys do not show a significant reduction in comprehensiveness of practice except in obstetric deliveries, which agree with other surveys . Much will depend on whether this is a continuing trend, or if the proportion of family physicians doing deliveries will level off or increase. The number of physicians offering shared prenatal care increased significantly.
Apart from the figures for obstetric practice, the picture of comprehensiveness we get from the surveys is at variance with the widespread impression of a withdrawal from hospital, nursing home and home care, and an increase in the number of doctors wi th an "office only" practice. I suspect that the cohort is atypical in this respect. When the pressure of demand increases, it is understandable that physicians tend to withdraw into their office practices, especially when comprehensiveness is so poorly r ecompensed. My own observation, however, is that the withdrawal from comprehensive practice began before the physician shortage. At a time when shorter hospital stays, scarce beds, and portable home technologies were making home care increasingly importan t, many physicians were unwilling to accept responsibility for their patients when they were sick in their homes. In urban areas, commercial deputizing services were often provided by physicians without a hospital affiliation, unable or unwilling to do ho me visits, and without access to a patient’s record.
Withdrawal from comprehensiveness has been felt especially by patients requiring end of life care in their own homes, and their family caregivers. This is sometimes explained as "not doing palliative care", as if palliative care was a specialty, like s urgery, rather than an obligation of physicians to care for their dying patients, sometimes in consultation with a colleague who has special skills. What does it mean "not to do palliative care?" When is the relationship terminated? When active treatment is discontinued? When things get too complicated and time consuming? When the patient can no longer come to the office?
We need to arrive at an agreement as to what it means to be a family physician - what services are essential to the role – and then to give a proper recompense to those who are providing them. Woodward and her colleagues report that 11% of the cohort h ad "restricted their practice within family medicine to such areas as sports medicine, emergency medicine, geriatrics, counseling and psychotherapy." It is important that we do not describe these doctors as family physicians. In restricting their practice , these 31 members of the cohort had ceased to do family practice. Many family physicians do develop special interests as well as continuing in family practice: for example, in children with disabilities, in eating disorders, in endoscopy, in wound manage ment or acupuncture. In doing so, they can enrich their experience and be consultants for their colleagues as well as generalists for their own patients.
A perspective on change:
Physicians have always had to adapt to change. Those in highly specialized fields are vulnerable to fluctuating demands for their service due to technological advances and to rising or falling morbidity rates. In the early 1950’s a whole servic e, with its own specialists, clinics, surgical units and hospitals, had to be dismantled when the anti-tuberculosis drugs accelerated the declining incidence of tuberculosis. Physicians in general fields are vulnerable to increasing specialization and tec hnological advances. I am old enough to remember the disappearance of major surgery from all except isolated practices. When the National Heath Service was introduced in Britain, general practitioner surgeons had to become either surgeons or general pract itioners. With few exceptions they could not be both. A few years later the same change took place in Canada. There was a good deal of sadness over this, and morale was low for several years. But it forced us to think about what was essential to being a f amily doctor, and what was not. Eventually, general practice was reborn with a clearer self-concept and an articulated body of knowledge. We are now at a similar time of rapid change and need to look again at what is the essence of family practice. In a t ime of fragmentation there is a need to define – for ourselves, our colleagues and our patients – what commitments can be expected of a family doctor.
It is paradoxical that fragmentation is occurring at a time when individualized care, by a doctor who knows the patient, has never been more necessary. The health status of each patient is "s unique outcome of the interactions between genes, developmen t, and environment, with roots in the past and potent implication for possible futures" . Every patient has their own disease.
Whatever the eventual outcome, I doubt whether it is possible to be a professional and to work strictly by the clock. Even when there are defined shifts there will always be exigencies that require us to make moral choices between conflicting obligatio ns. When work is a labor of love we do not leave it behind when the day’s work is done. I doubt also whether it is desirable to separate life and work in such watertight compartments. Medicine – especially family medicine – teaches us about life; and life teaches us about medicine. As Wendell Berry wrote: "If we do not live where we work, and when we work, we are wasting our lives, and our work too" . If a profession ceases to be a labor of love, we should be concerned.
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2. Eisenberg C. The implications of new genetics for health professional education. Josiah Macy Jr. Foundation Conference, New York 1998.
3. Berry W. The unsettling of America: Culture and agriculture. New York: Avon Books; 1978.