COLLABORATION BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS

The Gulf Between Preferred and Actual Practice

Study on the perceptions of medical residents and their educators of the roles to be assumed by future physicians in collaborative practice and their evaluation of future physicians preparedness for these roles

Marie-Dominique Beaulieu, M.D., FCFPC, Professor Doctor Sadok Besrour Chair in Family Medicine

Department of Family Medicine, Faculty of Medicine, CHUM Research Centre, University of Montreal

Louise Samson, M.D., FRCPC, Professor

Department of Radiology, Radiation Oncology and Nuclear Medicine Faculty of Medicine and Centre Hospitalier de lUniversit de Montral (CHUM), University of

Montreal

Guy Rocher, Ph.D., Professor Department of Sociology and Public Law Research Centre

University of Montreal

Marc Rioux, doctoral candidate Public Law Research Centre

University of Montreal

Laurier Boucher, professional social worker, MSW, Research Associate Doctor Sadok Besrour Chair in Family Medicine

Project funded by the Royal College of Physicians and Surgeons of Canada and and the Doctor Sadok Besrour Chair in Family Medicine

This research has received funding from the Royal College of Physicians and Surgeons of Canada as well as the Doctor Sadok Besrour Chair in Family Medicine of the University of Montreal. The project was approved by the Research Ethics Committee of the Centre hospitalier universitaire de Montral (CHUM) Research Centre. ISBN: 2-9807566-5-2 Cite: Beaulieu M.-D., Samson L., Rocher G., Rioux M., Boucher L. Collaboration Between Family Physicians and Medical Specialists, The Gulf Between Preferred and Actual Practice. Doctor Sadok Besrour Chair in Family Medicine Montral, 2005. 57 pages.

TABLE OF CONTENTS FORWARD AND ACKNOWLEDGEMENTS I1. BACKGROUND, APPROACH, RESEARCH QUESTIONS Everyone wants to head in the same direction, but where are we actually going?

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1.1 We have a consensus: A new medical practice will play a key role in current reforms

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1.2 A growing gulf between the preferred vision and actual practice

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1.3 The professional system: A useful tool provides a fresh look at professional collaboration in the health care system

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1.4 Training: Where professional identity is formed

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Objectives and method 9 2. FINDINGS Training, practices and career choices that do not always follow the general consensus or the official view

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2.1 So what exactly is a family physician?

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2.2 Collaborate? Sure, but who will do what?

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2.3 Collaboration can be learned! ... Really?

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2.4 Summary 27 3. OPTIONS Systemic problems require system-wide solutions

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3.1 Respondents proposals

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3.2 Our proposals 35 424. CONCLUSION 47 APPENDICES TABLE 1 Summary of Discussions on the Nature of Professional Collaboration and the Issues It Raises TABLE 2 Mail Survey Results, by Residency Program REFERENCES

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FOREWARD AND ACKNOWLEDGEMENTS First and foremost, I would like to take this opportunity to express my sincere appreciation to everyone who has helped make this report possible. My thoughts turn first to all the participants, the residents as well as their professors, who accepted to meet with us and answer our questions despite their already overburdened schedules. Unfortunately I cannot mention them by name, since of course their anonymity must be maintained as a condition for carrying out the study. I am also thinking of all those who made it possible to conduct our interviews: the administrative assistants working in various programs of study and the offices of graduate studies. To all of these individuals, I extend my sincere appreciation. I also want to thank the members of the Section of Residents of the College of Family Physicians of Canada who shared with me their perceptions of the issues when the study was still at a preliminary stage, and who helped to organize some of the focus groups. To my research collaborators who helped me develop the interview protocol and conduct the interviews and who read the interview transcripts and attended meetings to review this rich material and identify the best excerpts, thank you so much. As Principal Investigator, I would also like to extend a very special thank you to Guy Rocher, a seasoned sociologist and humanist who has been closely associated with Qubec history for half a century. Despite his many other commitments, he accepted to provide me with guidance in my exploration of a discipline that I have been practicing for over 25 years and that I still love as much as ever. Professor Rocher, your invaluable advice and suggestions have helped me dig deeper into my subject, trust some of my intuitions and wander down paths that might otherwise have gone unexplored. We hope that this report will be of assistance to all the stakeholders involved in the current reorganization of our health care system. It provides a better understanding of the issues faced in family medicine and specialized medicine and makes an important contribution to the search for innovative solutions. Marie-Dominique Beaulieu, M.D., M.Sc., FCFPC

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1. BACKGROUND, APPROACH, RESEARCH QUESTIONS

Everyone wants to head in the same direction, but where are we actually going?

Closer collaboration between health professionals is regularly presented as a key element in plans to provide the public with better access to high quality services.

But what do those primarily concerned think about collaboration? Do they share the vision of the role that society wants them to play? Do they feel

adequately prepared to assume that role?

This study consulted two groups that will have to implement the current series of reforms family medicine residents and specialist residents as well as

those charged with preparing them to step into these roles. 1.1 We have a consensus: A new medical practice will play a key role in current reforms Reforms implemented across Canada are trying to foster better access to quality care, care that is more continuous and delivered more efficiently. Better integration of care and a more judicious use of human resources are two of the preferred strategies advanced to achieve this end (1), (2), (3), (4). There is a wide consensus that the success of these strategies will largely be based on our ability to change current professional practices. To name just one of the arguments in support of this thesis, it is worth recalling that a combination of demographic changes and technological progress has now made managing chronic illness one of the major challenges faced by the health care system. Comorbidity is on the rise (over 35% of adults between the ages of 60 and 69 suffer from at least two chronic health problems; this proportion is 53% in adults over 80 years of age) (5). We have a specialized model for the management of clienteles defined according to specific health problems what is called disease management but this model is less appropriate for managing multi-morbidities. We therefore need to develop new models of professional practice, and a consensus appears to have emerged on a comprehensive vision of future practice. Primary care services and family physicians are in a better position to offer comprehensive care to patients and should be central to this practice. Effective mechanisms for communication will ensure that information flows between primary care practitioners and specialized services (6). In order to ensure that the available expertise is used in an optimal manner, professional roles will need to change. Medical specialists will need to stop providing follow-up care to patients who do not need their level of expertise and concentrate on acting as consultants (even more than they do currently), providing support to primary care professionals. For their part, nurses, pharmacists and other health professionals will take on more responsibilities. For example, they will need to take on certain

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roles that have traditionally been the domain of the family physician (1), (7), (4). Recent changes introduced by the province of Qubec to the law governing health professionals have addressed these issues, seeking the kind of flexibility that would foster these transformations (8). Of course family medicine, often presented as a key element in the new care system, has not escaped this trend towards redefining and adapting roles (9). In most industrialized countries, professional organizations of general practitioners and family physicians have taken clear positions by adopting a definition of the family physician in which a broad scope of practice, accessibility to care and continuity of care have been presented as the very foundations of the profession (10), (11), (12). 1.2 A growing gulf between the preferred vision and actual practice There is a vision of future practice a practice founded on closer collaboration between the various health professions, which then accept to adapt their roles that is clear and widely accepted. In the field, however, actual practice does not appear to be moving steadfastly in this direction. Indeed, practice is moving in the opposite direction. While health care systems are ready to make considerable room for family medicine, the profession does not appear willing to step in and adopt this vision. The actual number of practising family physicians is in decline. Medical students are losing interest in family medicine. Profiles of practice among general practitioners are tending toward narrowing the field of practice. At a time when there is a general shortage of physicians, the profession of family medicine has been particularly affected. The proportion of Canadian medical students opting to study family medicine was 40% at the

beginning of the 1990s and had fallen to 28% by 2001 (13). Changes in the profiles of practice of students graduating from family medicine programs in various

Canadian provinces reveal that a significant proportion of them (between 10% and 30%) are not offering general primary care in the first few years of their careers (14), (15), (16), (17). This proportion is as high as 56% among graduates who completed an additional year of emergency medicine (18).

In Qubec, an analysis of the billing patterns of all general practitioners suggests that only 50% have a

practice corresponding to what we understand as family medicine: 25% have restricted their practice to emergency and walk-in care, and 25% have little involvement in clinical care (19).

During the 2004 National Physician Survey (20), 13% of family physicians reported that they had

reduced their scope of practice over the previous two years, and another 25% said that they planned on reducing their working hours in the following two years.

The situation is no better with respect to collaboration between family physicians and medical specialists. Concerns had already been raised in 1993 with the publication of a joint study by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. It reported on problems achieving collaboration between general practitioners and

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specialists, and underscored the existence of negative prejudices on both sides (21). The 2004 National Physician Survey indicated that the situation had not improved (20): 33% of specialist physicians reported that they were unable to see non-emergency patient referrals

from family physicians in less than three months. Only 25% could see an emergency consultation within 24 hours.

30% of family physicians rated access to specialists as acceptable or weak. 50% of specialists qualified access to family physicians as acceptable or weak. This gap between practices observed in the field and the proposed vision raises many questions, particularly when we know that the vision is supported by leaders in family medicine. How do family physicians, who will have to perform increasingly complex clinical tasks, see their scope of practice,1 this key element of the practice of family medicine? What is their position on having to share their privileged relationship with the patient in a team setting, where nurses and other professionals play increasingly important roles? How do family physicians and medical specialists see their collaboration and the role that each will need to play in a collaborative practice? This last issue begs the formulation of new questions. Until now, for the most part our attention has been focused on collaboration between the professions. A major initiative has been launched in Canada, with the objective of encouraging collaborative practice among professionals in all the sectors of patient care (22). However, there has been much less interest in collaboration between members of the same profession, as if collaboration between physicians is taken for granted. Some experiments have suggested that this collaboration is anything but operable, and that developing a collaborative practice between the specialist and the general practitioner is still very much on the menu, with all the attendant hurdles to be crossed and therefore to be studied and understood (21), (5), (23), (24). 1.3 The professional system: A useful tool provides a fresh look at professional collaboration in the health care system In order to examine this new collaborative practice, and in particular the roles that medical specialists and family physicians will need to assume, we have adopted the systemic framework developed for the analysis of professions by Eliot Freidson (25) and Andrew Abbott (26). This approach takes both a concrete and penetrating look at the reality of professions and one that we believe is not sufficiently known among medical professionals, whether specialists or general practitioners. After giving due consideration to the general conditions of practice, we decided to bend the law and the official position by treating family physicians and specialists as two professions, professions that undoubtedly maintain close familial ties but that are in practice quite distinct. We will consider their respective position statements as the official view of these two professions and an expression of their preferred vision of practice.

1 In this report, references to scope of practice implicitly assume the goal of a wide scope of practice in family medicine.

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The family physician (27) The family physician is a competent clinician (comprehensive approach centered on the patient, expertise in a wide range of routine problems and in emergencies). Family medicine is a community-based discipline (practice profile adapted to the needs of the community; unselected and undifferentiated problems; varied practice settings; professional collaboration). The family physician acts as a resource to a defined population of patients (practice as a population at risk). The physician/patient relationship constitutes the essence of the role of family physician (understanding the human condition; providing continuity; defending patients interests).

The medical specialist (28) Expert Communicator Collaborator Manager Health promoter Scholar Professional

The professional system according to Abbott and Freidson The professional system is a collection of institutions through which members of an occupation can move ahead in society by exercising control over their own work. This privileged position is possible because the specific tasks that they carry out are different enough from those of most other workers that members must exercise control over their own profession. The two guiding principles of the professional system are based on the belief that certain tasks 1) are so specialized that they are inaccessible unless one has the training and the experience to carry them out, and 2) cannot be standardized. The idea of specialization, and therefore of expertise, is the core of the professional system. However, this concept of specialization is quite relative; someone who is considered a generalist in a given profession may be considered a specialist if their expertise is compared to that of other professions. Within the professional system, each profession is defined as a function of a group of tasks that are themselves established by jurisdiction. Each profession must constantly defend its legitimacy and its jurisdiction, whether in the public arena (before the general public, institutions and the State) or in the workplace, the main arena where professional work is negotiated on a day-to-day basis. This is where professional barriers are most poorly defined, particularly in times of staffing shortages, when jurisdictions are most vulnerable and ground can be won or lost. A disciplines ability to justify and defend its jurisdiction depends on its capacity to clearly establish its role and its effectiveness in the resolution of a series of problems. It is through professional work, the professional tasks carried out by its members, that a profession can establish its identity, its legitimacy and its jurisdiction in contrast with the other professions with which it is constantly interdependent. These tasks have three bases: objective foundations, subjective foundations and the ability to manage a system of specific codified or academicized knowledge.

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Professional identity The objective foundations of a profession are located outside the professional system and are characterized by four main factors: technologies, social organization (laws, institutions, etc.), a natural fact (such as illness) or a cultural fact (such as aesthetics or spirituality). The subjective foundations of professional tasks are grounded in practice and are the most important bases of the profession. Abbott categorizes subjective bases according to the three major phases in any professional work: the diagnosis and the treatment of problems, and the process of inference.

Diagnosis concerns how we understand and classify problems. The classification system can expose the profession to jurisdictional challenges. For example, the more a profession restricts how a problem can be defined, the more it leaves room for another profession to claim jurisdiction by proposing a more comprehensive solution to the problem. On the other hand, the more vague the definition proposed of a problem, the more the profession leaves itself vulnerable to another profession that would present a clearer and more precise definition of the problem. Two aspects of treatment can influence the vulnerability of a professional jurisdiction: the effectiveness of treatment and its complexity. For example, the less a profession is able to measure the efficacy of a treatment, the weaker is the professions claim to provide a true solution to the problem. The easier a treatment can be provided, the more it can be routinized and claimed by another profession. The process of inference that leads to a diagnosis and associates the diagnosis with a treatment also contributes to making the profession unique: the more direct the link between diagnosis and treatment, the more vulnerable the profession becomes, because its tasks can be standardized and delegated. The more the process of inference is complex and based on abstract knowledge and the more the related judgments are discretionary, the less the professionals position may be considered vulnerable.

Specific, codified or academicized knowledge. Professional work has direct ties to a system of knowledge. Professional knowledge gives legitimacy to professional work by clarifying its foundations and linking it to societys fundamental values, such as rationality, logic and science. It is through codified or academicized knowledge that the efficacy of treatments can be demonstrated. Thisknowledge also leads to innovations that offer the profession some protection through the development of new expertise. The world of codified or academicized knowledge is also where future professionals receive their training. A system of interdependencies Professions are interdependent. The internal structure of a profession is only one of many determinants of a professions ability to adapt to upheavals in the system, which is continually in motion and never remains in a state of equilibrium for long. These upheavals, the constant changes that can disturb the professional systems equilibrium, come as much from the external environment as from inside any of the systems constituant professions.

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The external environment includes the social environment and the cultural environment. Among the elements of the social environment that can disturb the professional systems equilibrium we should mention changing technologies and the organization of work, particularly the rise of bureaucratization and the creation of very large organizations. But according to Abbott and Freidson, the changes in the cultural environment play an even more decisive role.2 Their discussion highlights three specific factors: o The increase in the quantity and complexity of knowledge. Professions adopt different

strategies to deal with changing knowledge, and these strategies can have significant effects on their jurisdictions. For example, the need to manage complex and abundant knowledge may result in the creation of an expert system. This expert system, however, may make it possible to routinize certain practices that may then be more easily taken over by another profession. For example, the development of increasingly precise practice guidelines undoubtedly contributed to the development of the role of clinical pharmacist by enabling pharmacists to maintain that they are now able to treat patients and prescribe medication.

o Changing social values. Professions base their legitimacy on social values (what Abbott calls

the currency of legitimation). For example, science and efficacy are the social values upon which the professional system has traditionally been based. They have gradually been superceded by efficiency, accountability and integrity, and this has changed some of the rules of the professional system. Specialization is highly valued at the expense of general practice, a trend that harms family medicine. On the other hand, over the last few years we have witnessed a return to humanism and community values, a trend that could result in family medicine becoming more highly valued.

o The rise of universities. Historically, universities had to work their way into the professional

system, although they now provide most professional education. The relationship between universities and the professional system is unavoidable, given the importance of knowledge in professions. This relationship creates tensions between academics and practitioners in the same profession; the former set the criteria of good practice by which the work of the latter is evaluated.

Internal relationships between members of the same profession One of the fundamental aspects of internal relationships between members of the same profession is the ability of members to differentiate themselves from each other, assume a certain amount of power and establish their own professional or personal path within a given jurisdiction. This capacity for internal differentiation offers needed room for member autonomy and the pursuit of personal aspirations, but it can also become a source of friction or tension. We will briefly discuss four ways in which members of the same profession can differentiate themselves from each other. o Intra-professional status. Since a profession is organized around a system of knowledge,

higher status is bestowed upon those who are more involved in the organization of learning and the generation of knowledge. This can be a source of problems or discomfort for professionals working in the field. In the eyes of clients and members of other professions

2 For more information, read Abbott op. cit. Chapter 7: The Cultural Environment of Professional Development (pp. 177-212) and Freidson, op. cit., Chapter 7: Bodies of Knowledge (p. 152-178).

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with whom they have daily contact, practising professionals give the profession legitimacy through their work. Yet within their own profession, practising professionals generally have the least status, or at least they hold less prestigious positions than colleagues respected for their scholarship.

o Differentiation of clienteles. The issue of differentiating clienteles can have considerable

impact. For example, some specialties or sub-specialties may abandon certain clienteles, leaving them available to another profession. Abbott provides the example of nurses, who entered the field of primary care after it had been somewhat abandoned by physicians. According to Abbott, internal differences in status, combined with different clienteles and different ways of organizing work, can create large disparities in income, power and prestige within a profession.

o Differentiation of workplaces. Two dimensions are important here: the issues of income

(whether it is from an independent source or by salary, which carries less prestige) and type of work (i.e. working in a group or alone). For example, in medicine the hospital has become an important workplace, just as health management organizations have become in the United States. As a result, physicians who practise outside these structures have lost part of their prestige and power.

o Differentiation of career plans. Career plans are important because they can contribute to a

certain demographic rigidity that could make it difficult for a profession to adapt to changing circumstances. For example, staffing shortages or surpluses will have an impact on a profession and its role in the system.

Adopting this analytic approach to the study of collaborative practice inevitably leads to an examination of the boundaries between the various professions, but we also need to look at each professions functions, roles and identity. This last issue is particularly important, since professionals can only develop effective collaborative relationships if they have, from the outset, a good idea of their professions identity and its area of expertise. In order for collaboration to be effective, one must be able to establish and assert ones expertise and acknowledge and respect the others expertise. Interviewing physicians about collaboration therefore necessarily involves asking them about how they see their respective role and professional identity. This is an issue that has become more critical for family physicians at a time when the available data suggest that they are deeply concerned about their professional identity. 1.4 Training: Where professional identity is formed The training of professionals is clearly one of the factors influencing how the system functions. In health, the educational system plays a particularly important role in how professional identity develops (25), (26), (29), (30) and how professionals learn to collaborate (31). The apprenticeship model used in medical training in clinical settings has a significant effect on how physicians internalize professional roles (29), (30).

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The initial training received by professionals is undoubtedly one of the main levers for implementing collaboration in the health care system (22), (32), (33). But even here, observers have underscored a break between the proposed vision and the reality of practice in training environments (34), (35), (36). Does clinical training offer students educational settings and role models that are appropriate to the modes of functioning we want to emerge in health care? Do practice training environments enable students to acquire needed new habits, including learning how to work in a collaborative practice? Certain programs have already responded to these issues by introducing changes in direction, putting more emphasis on the development of learning experiences in the community, in a rural setting and/or in a multidisciplinary context. The development of attitudes and aptitudes for collaborative practice has become one of the stated objectives of all the organizations and professional orders responsible for training health professionals. In medicine, the Royal College of Physicians and Surgeons has identified collaboration and professionalism as the fundamental competencies required in the practice of specialized medicine (28). Studying the professionalization process in medical specialties is not new; several sociologists and educators became interested in the subject as early as the 1980s (30), (29). It is nevertheless remarkable that these studies limited their examination of family medicine to a strict minimum. This is probably a reflection of the level of interest for the discipline in health care systems that are oriented towards specialized medicine. To fill this gap, we urgently need to know how educators and young physicians reaching the end of their training (in family medicine and in specialized medicine) perceive their respective roles in collaborative practice and, in addition, to have their evaluation of the training they received to prepare them for these roles. Summary This study has heard from family physicians and medical specialists who have reached the end of their training as well as their educators. It explored how these young professionals perceive their future roles in a health care system based on collaborative practice, and how they see their specific contribution to this new form of practice. More specifically in terms of collaboration between family physicians and medical specialists, this study also seeks to deepen our understanding of how various residency programs implement and attain training objectives related to competencies in collaborative practice that the Royal College of Physicians and Surgeons of Canada (28) and the College of Family Physicians of Canada (27) have identified as priorities.

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Objectives More specifically, the studys objectives were: 1. To survey training objectives with

respect to collaborative practice competencies in four residency programs (family medicine, general psychiatry, internal medicine and general radiology) in Canadas 16 faculties of medicine.

2. To select four of these faculties and

conduct a comprehensive study in order to:

2.1 Explore how future medical specialists and family physicians reaching the end of their training perceive the role played by their discipline in the Canadian health care system and how they see their roles in fostering an effective interface between primary care and specialized services; 2.2 Determine the extent to which these future professionals believe that their learning experiences and their educational institutions have prepared them to step into these new roles; 2.3 Compare these perceptions with the collaboration goals in their respective training programs as defined in the programs official documents and compare these perceptions with the positions of educators in charge of meeting program goals.

Method

The study was conducted in two phases that ran from October 2003 to December 2004: A mail survey was sent to each of the

four residency programs in the 16 faculties of medicine across Canada. The selected programs comprised family medicine and three other programs that have strong functional ties to family medicine and primary care medicine: general psychiatry, internal medicine and general radiology.

A qualitative study was conducted in

four faculties of medicine: Memorial University of Newfoundland; the University of Sherbrooke, in Qubec; the University of Toronto, in Ontario; and the University of British Columbia, in Vancouver. These faculties were selected according to two criteria: whether or not the faculty had a stated community-based orientation and how well the final selection would represent the various regions of Canada.

The project was accepted by the Ethics Committee of the CHUM Research Centre. In addition, the qualitative sub-study was accepted by the ethics committees of the University of Toronto, Memorial University of Newfoundland and the University of British Columbia.

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The mail survey. A letter was sent to all the program directors requesting copies of learning objectives for their residency programs. The response rate varied between 60% and 80%. The objectives were analyzed by two physician-investigators (M.-D. B. and L.S.). The analysis was based on the following criteria: The presence of objectives. The type of objective: whether they were institutional objectives, i.e. objectives prepared by the institution itself, or the objectives of the Royal College of Physicians and Surgeons. The degree of specificity: a general objective describes a comprehensive skill and a specific objective describes expectations in more detail. The description: the objectives were classified according to whether they represented a targeted general competency or intermediate objectives for attaining the competency. We also noted if the objective specified the type of collaboration (interprofessional with a family physician) that was sought. Finally, the concepts of collaboration were listed and classified as either traditional (leadership, understanding of roles, teamwork, etc.) or innovative (communities of practice, conflict resolution, diversity and tolerance, etc.). The qualitative study was conducted with focus groups and individual semi-structured interviews. In order to cover the entire pedagogical chain, we approached four types of respondents in each faculty: o The vice-dean of graduate studies

(individual interview), o The director of the program concerned

(individual interview), o Faculty members from the program (focus

groups and individual interviews), o Residents in each specialty (focus groups

and individual interviews).

Residents in family medicine were selected in such a manner as to ensure representation of the various training environments in each program. The interviews were led by three investigators (M.-D. B., L.B. and L.S.). Group interviews were attended by an average of three specialty residents (out of a possible five eligible residents) and an average of six family medicine residents. Some specialty residents were met in individual interviews. Interviews with professors were either conducted in groups (of three to six people) or on an individual basis. A total of 40 interviews were conducted with 91 participants.3 We reached saturation in terms of the points of view expressed by our respondents (no new themes emerged in the final interviews), with the exception of radiology, where the participation rate was not as high. The results are provided, at times according to the category of respondent and at other times according to whether the respondents were family physicians or specialists. Finally, although we selected universities that would enable us to contrast the results according to a stated community-based orientation, we found no differences in the ideas expressed by respondents from these two groups. Our findings have therefore been presented giving no particular attention to this parameter. N.B. To simplify data presentation, we have integrated findings from the analysis of residency programs with findings from interviews.

3 All the vice-deans of graduate studies and all the program directors (with the exception of two in radiology) participated in the study. We met 16 professors of family medicine, 14 specialist professors, 25 family medicine residents and 18 specialty residents.

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2. FINDINGS

Training, practices and career choices that do not always follow

the general consensus or the official view

Differences were found at various levels: between family physicians,

between family physicians and specialists, between residents and their educators,

between the official training objectives and the actual training received, between the vision of the role of each party in a collaborative practice,

and among ideas on what consitutes collaborative practice. 2.1 What exactly is a family physician? Two interview excerpts provide a good description of how family physicians (and indeed the majority of our respondents) view family medicine.

The thing about family physicians is that after they treat patients, they also do the follow up. They carry long-term clinical responsibility for their patients, independent of the patients age (pediatric, adult or geriatric) or the illness. This requires a wide renage of skills because various approaches are required. Sometimes family physicians provide curative care, sometimes they follow a chronic illness or provide palliative care, where the focus is more on the patients comfort. As a family physician, one has to be able to move comfortably through all this. In addition, sometimes you have to defend the patients interests. There are times when the patient has trouble understanding the system, knowing where to turn or how to access certain types of treatment or referrals. The role of a family physician includes ensuring that the patient has all he may need in terms of treatment. Its like explaining everything thats going on being able to educate the patient. (Resident in family medicine) I can see that family physicians are really the foundation of the family medical system here. They provide treatment through the medical system. I think they also act as very strong advocates for their patients. And in order to do that, in order to have continuity of care, the relationship with the patient is very important. (Resident in family medicine)

Generally speaking, scope of practice, continuity of care and the relationship with the patient formed the core of respondents definitions of family medicine. In terms of what we heard, there seems to be a wide consensus among family physicians about the nature of their profession. Although the view is widely shared, two different perspectives on the meaning of scope of practice have been proposed.

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Some of the family physicians and most of the specialists we interviewed define the practice of family medicine on the basis of the functions of the family physician, and they consider two of these functions the ability to offer a first response to any enquiry from a patient and the coordination and integration of the care experience as the disciplines foundation and core.

I think the basis of family practice is the continuity of care for the patient, and, of course, thats medical care. But theres a whole lot of other things that enter into that, including the social context and the psychological care. But for the most part, I see family practitioners as providing continuous care, a kind of first-level entrance care for the patient. (Resident in family medicine)

Other participants based their definition of scope of practice on the practice settings: the medical office for routine care, the emergency room, the hospital, the delivery room, etc. This representation refers more explicitly to the community dimension of the profession: it draws attention to the responsibility of the family physician alone or in a group to respond to all the primary care needs of his or her clientele and, in small communities, to respond to the needs of the community as a whole. Respondents used the term full-service family physician.

So those are my hopes: that we will continue to have family doctors who will be there advocating for patients both in the community and in the hospitals and nursing homes, doing obstetrics, totally involved in all aspects of patient care. Because I do think, both economically and personally, that that's the best way to provide care for the whole country. (Family physician educator)

There are therefore two ways to look at the practice of family medicine, or the daily application of this understanding of the discipline as expressed by a majority of our respondents (scope of practice, continuity of care, relationship with the patient). But independent of the criteria respondents used to define their professions, the interviews revealed another split, one that appears to be both more significant and more revealing. Ambivalence about scope of practice: the siren call of specialization Although the majority of participants stated that a wide scope of practice is one of the fundamental characteristics of family medicine (effectively agreeing with the dominant professionnal view), their responses also very clearly revealed an enduring conflict between scope of practice and expertise. This conflict, which captures the tension between family medicines holistic approach and the strong trend towards specialization in medicine and, more generally, in society as a whole, was conveyed through many questions and doubts.

It is a huge scope of practice. Which is one of its biggest advantages, but, at the same time, its always possible to do a little too much. Divide yourself in too many different ways that sacrifice your personal life, aside from medicine. Such as attending to patients, being very conscientious, and doing emergency shifts. (Resident in family medicine)

For me, at this point in my training, its expertise as well. Its just to be feeling that Im able to do a good job at everything. And I honestly dont feel that I can stay on top of it all, theres something that has to be cut. (Resident in family medicine)

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I think part of that is for fear that its becoming so complicated that its hard to maintain your competencies. Subdividing family medicine into family medicine, obstetrics or whatever. But maybe thats what the future holds. Well, were already doing that to some degree, there are a lot of examples of how were all already choosing a particular area of focus. However, I think in the training program we still kind of encourage people to be generalists. I think theres a group of people who go into family medicine because they see a holistic aspect related to health and human beings, one that is lost in a specialists procedure on a coronary artery. Maybe there should be a sub-specialty of holistic family medicine. (Educators teaching family medicine)

These doubts and this questioning leads future family physicians to conclude that the legitimacy of a specialist will be more easily won than their own, even if they believe that their functions as first respondent, coordinator and integrator are critical to the health care system.

I had specialist friends who said, Youre just in family medicine. I said, But I have a much broader range of skills than you. I will be able to deliver a child, care for a grandfather or treat depression In a university hospital, family medicine has had a really bad rap. (Resident in family medicine)

For all intents and purposes, to hear it from family physicians whether residents or educators the degree of recognition accorded to specialization represents a thorn in their sides and a constant source of concern. Some of them mention the extent of current knowledge, the way the health care system is organized and their life objectives, and simply conclude that it is impossible to sustain such a wide scope of practice. Even those who say they are comfortable with a status as non-expert acknowledge the importance of being an expert in something.

I am feeling a little bit overwhelmed by all aspects of family medicine. Therefore, I want to specialize. I am considering obstetrics, and annual family follow-ups, and probably palliative care. I do have adults in mind, I dont exclude them, but I would probably try to focus as much as I can on a specific population. Because doing everything just seems too much. Considering my ability to absorb information, I think that I could be a specialist instead of doing everything. (Resident in family medicine) We are supposed to know everything. That is what our teachers are telling us. Yet, the movement is towards specialization. And I understand why My whole goal since being in internship has been to try to figure out what it is Im going to eliminate from my practice, and what Im going to practise. Thats been my goal: it hasnt been about keeping all my skills, but trying to figure out how many to lose. (Resident in family medicine) You just need to see both sides. No one nowadays can be a Jack of all trades. You have to maintain your scope of practice, but not be excessive about it. (Resident in family medicine) Were generalists. But we also have an opportunity to be a little bit of a specialist while being a generalist. And I like that idea. I like the idea of knowing a little bit more about an area because, as you said, we know a lot of things. But, you know, theres just no time. (Resident in family medicine) In fact, I think the subtle message out there is still that if youre not doing comprehensive care like what you might see in a rural community, youre not a family doctor. (Program director)

Finally, and still on the same theme, some respondents were concerned about the trend among departments of family medicine to introduce third-year specialized programs:

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We are concerned about a trend in training in which departments seem to want to develop what I will call the specialized family physician. We have also noted that many family medicine residents have a tendency to develop an area of expertise. In my opinion, this is a misreading of the mandate or our definition of the family physician, who is someone with a wide scope of practice, not someone with a narrow or focused practice. I sense there is a movement in this direction, and I am afraid that we are heading in the wrong direction, forming not family physicians but specialized family physicians (Vice-Dean)

An enthusiastic commitment ... that we would just as well put off for a bit This tainted ambivalence that one would maintain between scope of practice, an ideal that is often considered unattainable, and expertise, a source of professional prestige, is in some ways reflected in how residents view their entry into the profession: with an enthusiasm that is tempered with a certain prudence. Family medicine residents, well aware of the current staffing shortage, feel that they enjoy considerable freedom as they set out on their professional careers. They are proud to be family physicians and appreciate the diverse types of pratice the profession affords. Given their levels of debt, financial considerations figure strongly in their choices. Family medicine residents see two career streams. Some of them immediately begin a career in a practice setting where they plan on having a career. For example, this is the case among residents who set up practice in more remote regions, particularly in British Columbia and Newfoundland. They are planning a very diversified career and opt for group practice. Others, a larger group, see the start of practice as a point of transition. They do not want to commit to working with a specific clientele, a group of colleagues or a community. Such a commitment is made even more difficult by the fact that they still do not have much stability in their personal lives. They therefore prefer having the flexibility to be able to try out several models of practice and to consolidate (not lose) the hard-won skills demanded in hospital and emergency practice.

In my first year of practice Im going to be on a very steep learning curve. Ive chosen an environment where I dont have to actually learn a lot about billing, either. Focusing on clinical medicine is exactly what Id like to do, and not worry about the business aspect of billing. I went into medicine because I like people, not numbers and that kind of thing. (Resident in family medicine) The piece of advice a family physician keeps giving me is you just keep adding on as you go along, and I think thats what Im really going to try to do when I start out: start out small and see fewer patients and then, if I want to add, I can. Im definitely not in a rush to check into a practice because I know how hard it is to relocate. So Im going to stay local for a while. (Resident in family medicine) You have to figure out for yourself what you want out of life, out of your practice, out of your different activities. Once these are established, then youre able to present it to your group and explain it according to the situation, taking into consideration not only your realities and limits but those of your community and the area in which you live and practise. (Resident in family medicine) Because of all those unknowns, Im kind of torn between the decision to just take something thats easy and thats already set up, versus going for something that I think I would like better but having to deal with all the starts And also I think reimbursement is a big issue in terms of starting up your own practice. I mean, youd have to see enough patients, working on a fee-for-service basis, to actually pay the bills and make a salary, as compared to people who go into walk-in clinics where

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things are all set up for them and they can see more patients with less complex problems and walk away with a better pay stub at the end of the day... Also, finding the right person to share a practice with is another big issue. Would we be compatible? How would that work? Would the patients who start out with me be comfortable seeing the other person when Im not there? Those types of issues. (Resident in family medicine)

Changing values and aspirations across different generations of family physicians Finally, this discomfort within the profession of family medicine has opened another gulf, this time between young physicians who embrace the profession and physician educators who seem to have difficulty letting go of the traditional view of family medicine. Several residents therefore feel judged by their elders and their professors and report that the latter adopt a kind of doubletalk. On the one hand, what family medicine educators say encourages students to find a balance between their professional and personal lives. But in fact the residents sometimes have the impression that they disappoint their elders and their professors when they decide to restrict their practice. Generally speaking and in contrast to their professors, the residents do not have the feeling that there is a crisis in family medicine. Some of them feel guilty, or at least uneasy and torn between two sentiments: a sense of responsibility to meet a societal need and fulfil the vision that the discipline has of itself and a sense that it is impossible to do it all, to incarnate the entire discipline in their individual practices.

This happened in just one day. I literally had a talk with a doctor who works part-time in palliative care and kind of feels the same way I do about family medicine. And in the same day, another who works in palliative care was quick to say, Those hobby doctors, they just arrive and theyre just a hobby doctor, and they want to make the big bucks. But they dont want to work, they want to work part-time, and no one is getting their work done... Within the same day, Ive been told, This is how I chose to do it and why. I also realized that I will always have to deal with people who are thinking that Im not doing enough work. (Resident in family medicine) A lot of the supervisors we work with are sort of stellar family physicians who do a lot of things, who cover a lot of areas in their practice. And I, for one, feel a little bit guilty when they ask me what Im doing next year and I say that Im going to do OB and palliative. I feel they are disappointed if I say, Oh, Im going to work in a clinic or do some walk-in shifts... Heaven forbid walk-in! Thats sort of the subtle pressure: Oh, thats nice.... (Resident in family medicine)

I think theres also sort of a subtle pressure to get new family doctors to practice in comprehensive care, and we want this balance in our personal life. I feel there is pressure to do more than just family medicine, like youre not living up to expectations if you dont practice in some other area of medicine like palliative care, emergency or obstetrics or that sort of thing. (Resident in family medicine)

For their part, professors also note this generation gap. They speak of a deep commitment to their discipline. Several of them seem to be watching, powerlessly, as their graduates lose interest in the model of the complete family physician. They speak of it with some regret and sometimes with bitterness. They perceive this generation gap as a conflict of values.

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One of the reasons Im in family medicine is because of that: be a holistic physician and get to know people at various levels of their experience. And I see it as a challenge to try and inspire students to continue to hold on to that vision at the same time that were spreading out their duties over a larger group of people, both specialists and other health professionals. I think its important that someone keeps up with all that. I see it as a challenge, because those of us who are teaching are all strong believers in comprehensive family medicine, and a lot of the residents who come through are not interested in comprehensive family medicine. And thats a challenge too, to teah people who do not share your vision. (Family physician educator)

Fortunately, there is always the relationship with the patient... Unable to define themselves in terms of a specific expertise, the traditional way professions define themselves, family physicians fall back on what is generally considered one of the basic characteristics of their profession: the relationships they establish with their patients. This serves as an anchor for all our respondents in family medicine, both residents and professors. Family physicians find their raison dtre in the relationship with the patient.

The most exciting thing is being able to practise medicine one on one, being able to have a patient of my own, who I follow and get attached to, and he gets attached to me. (Resident in family medicine)

I think thats part of why you choose family medicine, as opposed to people who choose gynecology or surgery. I really do, I think theres something about wanting to please people. Thats partly why we choose family medicine. We love to be near people and then seeing tangible small-scale results. Theres a relationship, a bond, and thats probably important to us. (Resident in family medicine)

However, here again the position is partly ambivalent and tinged with paradox, because if the relationship with the patient is the main quality in the practice of family medicine, it can also be peceived as a burden.

I think one thing about family medicine is that you have long-term commitments to your patients, which can be scary as well, because youre worried about picking on patients you may not like. (Resident in family medicine)

Has family medicine reached a critical threshhold? All the physician educators interviewed, whether generalists or specialists, spoke of a crisis or of danger. Several family medicine educators spoke of the profession as an endangered species.

My fear is obviously that we wont have family medicine in ten years, that it will be all specialists or GP-specialists. In other words, that GPs would pick out different disciplines that they would specialize in, but nobody would be doing the whole scope of family medicine. Which is very scary for me, someone whos probably going to make more and more use of the system over the next ten years... (Family medicine educator)

However, others pointed out that the situation plays out differently depending on whether your practice is in an urban area or in one of the regions.

In the city I see family physicians tending, for a variety of reasons, to move away from full-service practice and into more focused practices, leaving the continuity aspect of care, or, if you like, certainly

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the comprehensive aspect of care. I see patients having to spend more time in emergency rooms and walk-in clinics in order to get primary care. So that is a very general statement about the urban environment as I see it. Thats not to say that all family doctors are moving in that direction, but increasingly it seems that its very difficult for a variety of reasons for family doctors to provide the old traditional broad-based family medicine service. And that stands in sharp contrast to family physicians working in rural and regional communities where family doctors do the whole range of family medicine, including intensive care and emergency medicine, and in some small communities where family doctors do the whole range of family medicine plus anesthesia or advanced obstetrics. So I guess I see an evolution in two streams: one is increasingly focused and the other is, in a sense, increasingly broad: that is, in rural communities, as specialists tend to be either forced to rotate or are voluntarily rotating through larger concentrations and larger communities. (Family medicine program director)

Others are of the opinion that family physicians are condemned to an impossible practice, noting how little the profession is valued in the health care system. Do we expect too much of the family physician?

Its a very high level of responsibility to feel that you are responsible for all aspects of your patients health and that you will be held responsible for it. So when your patient shows up in emergency with an MI and its deemed to be because her LDL wasnt brought down to 2.0 and her HbA1C was over 0.07, you know, just how much responsibility can you take for it? And yet, that is sort of how the family physician is being viewed. I think people are feeling that its not appropriate to shoulder that kind of responsibility, and they dont want to. (Family medicine program director)

Finally, many respondents believe that the trend towards specialization among family physicians represents the real and principal danger to the professions survival, because the system has a vital need for an integration function, and up until this point this function has been fulfilled by family physicians. If they stop performing this function, someone else will have to step in and take their place. 2.2 Collaborate? Sure, but who will do what? Generally speaking, the respondents acknowledged that the question of collaboration between family physicians and medical specialists was not a problem that captured their attention. Collaboration is taken for granted. The professions may rub elbows and respect each other, but they are moving down parallel paths. Even though all family medicine participants reported positive experiences with collaboration, their experiences with specialists were generally quite negative, and vice versa. Family physicians and specialists generally share a common understanding of their respective roles, but their views indicate a certain frustration with respect to how this role is performed. Respondents spoke of a growing distance between the two professions in terms that revealed ingrained prejudices on both sides. 2.2.1 Similar notions As we will see below, the interviews with participants revealed several inconsistencies between the official view and actual collaborative practice, yet, contrary to what might have been expected, these differences are not rooted in disagreement about the nature of their disciplines.

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The specialist: a consultant Generally speaking, the two professions appear to agree on the role of specialists: physicians treating patients with complex problems, facilitating access to specialized services, providing information and acting as educators and consultants. In collaboration between the two professions, it is the specialists role as consultant that comes to the fore. It was the psychiatry residents who best expressed this idea:

When I discharge a patient and he returns to his community, I have to ask myself how his family physician is going to handle it. Its clear that in this situation my team and I have a training role to play, in addition to maintaining a certain presence in the case. We send the patient home, but if there is any doubt or any type of problem arises, we are still there, because yes, there are risks. (Resident in psychiatry) Because the childrens hospital is a kind of unique resource, my part is more doing the consultation, feeding back recommendations to the family doctor, and then, maybe, doing more intermittent follow-up, like in three months or in six months, and checking to see hows the plan going, making adjustments to the plan. Not doing the actual, immediate follow up. And then, with the community mental-health team, I think theres also a role where I try to do some kind of training and try to export some of the actual treatments. (Resident in psychiatry)

The family physician: the quarterback of the health care system The specialists notion of family medicine is essentially the same as how family physicians see their discipline, including doubts about whether it is actually possible to fulfil the role in practice. Most of the specialist physicians interviewed, both the residents and professors, feel that it would be impossible to provide the public with medical services without family physicians. The family physicians expertise in evaluating and managing a braod variety of cases is widely recognized. The functions performed (accessibility to, continuity of and coordination of care) are considered vital. Specialists also acknowledge the unique relationship between the family physician and the patient, a relationship that is built up over time.

Obviously, there are two different roles, and those two roles are equally important. The family doctor is, from my angle, a primary health care provider who looks after all the primary health care needs of his or her patients. As I interact with family doctors as a specialist, I look at them as being quarterbacks. The family doctor controls the overall care of the patient. In other words, he may receive expert advice from a consultant or whatever, but Im talking about the ownership of that patient, the primary care provider, the person who coordinates all the health care provided to an individual: its the family doctor. (Director of an internal medicine program) The core business is really the presenting physical complaint, or any complaint, in the context of their family and general environment. Then, once you make that decision, as to where the issue is, you as a family physician may not have time to pursue it. (...) So, what I would see as the core of family medicine is really what is inherent in the name. One thing is continuity of health care. As specialists, we are not in that business. They are the hub, in my opinion, of the health care system. We, as specialists, are the spokes. We go into the various spokes. The hub of health care provision, in my opinion, is continuity of health care. (Vice-Dean)

Compared to what we do, I think theyre experts in communication, and thats a good idea as it relates to their patients because we (the specialists) have the luxury of being able to focus on an issue, a specific issue, for the most part. But the family physician has to deal more with the patients and their

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problems in the context of their lives over a long period of time. He has to take the time to build a relationship thats therapeutic, a relationship of trust And you come to admire them for their tolerance and their patience. I think thats what they do very well. And we could learn from that. (Resident in internal medicine)

I have always said that I have great admiration for family physicians, because in order to do what we ask of them, they must retain an enormous amount of knowledge. You have to be good in cardiology, in pneumology, in gastroenterology, in obstetrics, in infertility, in this, in that.... Its incredible! In fact, the scope of medical knowledge has become enormous. And we are asking people to master it all... (Vice-Dean)

Other specialists presented a different point of view.

I dont think everybody should be doing everything. So I dont think the physician should be delivering babies, seeing children, looking after an infarctus, going to assist surgery... I mean, theres a reality that has to be faced: you need to divide your time. And I think that within a family practice there are people who have technical needs, there are people who have psychiatric needs... So I think that family practice trainees should gear their practice, to a large extent, around their interests. But once their interest areas are defined, then I think they should be concentrating on an area that has some component of another area. (Specialist in internal medicine) I come from a different perspective because I trained in the United States and practised there as a general internist when I did primary care. So I have bridged the gap (between primary and secondary care) myself. I took care of the patients when they were in the hospital and I followed them as out-patients. (...) I think that in terms of taking care of adult patients, its a far better system. (...) But its not the way the Canadian system is set up. Its just a different philosophy about how you do things. But there is no doubt that theres a gigantic lack of continuity between what happens in the hospital and what happens when people go to their family doctors. (Specialist in internal medicine) I see family medicine as quite beleaguered. Burdened. And the burdens are multifold. One is that urban family practice, in my opinion, has shifted, and it has shifted because there has been a movement in the specialties to fragment. We have become more and more sub-specialized. And so the practice of family medicine in an urban center consists mostly of doing assessments and dispatching, which I think is not as rewarding to physicians. In the rural areas, we have the opposite problem. The specialists arent available, so family physicians are burdened with having to do too much because they dont have access to the many levels of specialties. (Vice-Dean)

At this point of our report, it is important to point out that the specialists we interviewed often see themselves as powerless observers of the identity crisis in family medicine. Even though they are affected by its repercussions, they do not feel implicated in the search for solutions. They only ask thenselves where family medicine is heading.

I think that there are probably all sorts of federal policy, monetary and financial issues... But there is a crisis. I have the impression that family physicians are trying to reposition the profession in terms of the nature of their work, but they are confronted with all sorts of problems that set them off on tangents, targeting very specific approaches. I dont quite know how we are going to get out of this mess... (Vice-Dean)

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The wait-and-see attitude towards the condition of family medicine and the lack of interest in participating in the solution that we observed in our interviews with specialists was confirmed by a family physician in a strategic position.

Theres no incentive for specialists to change. I dont think that they would want to change, and, in the current system, there would be no real motivation. I dont think they feel any altruism toward the system or toward primary care, or any personal responsibility to make it easier for family doctors. (Director of a family medicine program)

2.2.2 but somethings holding things up There does not appear to be a major disagreement on the roles that each profession should play in the health care system, working in the field; on the other hand, collaborative practice by the two professions runs up against certain obstacles and does not always meet expectations. Issues were raised about responsibilities, expertise, family physicians distancing themselves from the hopsital setting, and changing roles (see Table 1). Responsibilities: before they can be shared, they must be divided up It was the specialty residents who had more perspective on the issues posed by working as consultants in collaboration with family physicians.

In my two years as a senior resident, what I learned was how to be a good consultant. It isnt easy. Particularly in internal medicine, where we want to do it all, control everything, while the consulting role is about learning to be clear in our oral and verbal communication, to let people make their own decisions while offering alternatives. I have seen practices where people didnt collaborate very well. In addition to this being a problem in itself, it makes people in primary care afraid to act: they want us to do everything. In other settings, we are able to talk to the family physician, even if he or she doesnt have our level of knowledge in this specific area. When they did have enough knowledge, they could discuss this or that aspect that we hadnt seen, as colleagues. We didnt try to impose on them, do whatever we had to do and just leave them with the paperwork. When the family physicians knowledge was incomplete, we explained things, knowing that there would be less need for our input the next time around. (Resident in internal medicine) Family doctors must realize that, when we do write back to give them advice, we expect that the advice will be heeded. We do appreciate it when we send our advice in the form of consult letters to family doctors and the advice is recorded and recognized. So I think that the family doctor and the specialist must work together as a team, but we do have different roles. (Director of an internal medicine program)

Once again, it was the psychiatry residents who had the clearest idea of the kind of expertise that the family physician has and needs. In the relationship they establish with the family physician the latter assumes the role of manager of patient care and the former acts as a consultant the psychiatrists particularly appreciate two aspects of the family physicians expertise: their mastery of physical medicine and their knowledge of the patient.

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Specialists are particularly frustrated by certain situations with or attitudes held by family physicians: when they see that the patients health has deteriorated while in the care of a family physician, when their recommendations are not followed and when the family physician is seen as being cavalier in his or her approach to making the consultation request. But the main problem for these residents has to do with their responsibility. Even though they feel mutual respect and trust are very important, they believe the question of professional responsibility lies at the heart of collaboration. In order to collaborate, professionals must be able to clearly distinguish the responsibilities of each party. Participants identified two fundamental dimensions: availability and expertise. Availability. Both professions raised the issue of availability. The specialist, particularly when dealing with frail and unstable clienteles, wants to be sure that the family physician will be sufficiently available and have the resources to provide follow up care. The family physician wants to be sure of having quick access to the specialist for an opinion and, if required, for a hospital admission. Otherwise the result is the same: the physician is stuck with the patient and must carry the responsibility. Expertise. Rare was the specialist physician who, when asked about the nature of family medicine, raised the issue of a lack of expertise as one of the professions limitations. On the contrary, most deplore the trend toward restricted scope of practice, which paradoxically results in specialist physicians providing primary care. On the other hand, expertise comes up again as a key issue when they talk about conditions for effective collaboration between specialists and family physicians. They also mentioned: Conditions of practice for generalists:

Actually, its getting more and more complicated, and it may be that general practitioners will have to refer more, and certainly to interact more with specialists. You feel the pressure on primary care, and it raises questions about their capacity to do everything in the time they are given. (Resident in internal medicine)

Quality standards that appear sometimes different from their own:

The other issue with general internal medicine is oftentimes they refer a specific problem to us, so we investigate it further. And in the process of doing the history and physical theres another issue that needs to be dealt with or some unexplained weight loss... And I find that a little surprising sometimes, to be honest, that a really obvious physical finding might have gone undetected, or the potential implications of it were not identified. And the other thing that Im a little bit concerned about is whether or not there are slightly different standards as well, depending on where you are. (Resident in internal madicine)

Training issues, particularly with respect to the knowledge needed to follow the great chronic

pathologies such as heart failure and mental health problems. I think that we have completely unrealistic expectations about what family practice doctors should be able to do. (Specialist in internal medicine)

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Specialists isolate themselves These criticisms of others shortcomings are not just a one-way street; family physicians also have grievances about their specialist colleagues. They perceive a certain arrogance in the attitude of these experts and mention problems gaining access when they need an emergency consultation. Most of them complained of the profession being somewhat closed. The specialists did not deny that these complaints could have a basis in reality. Several of them mentioned a lack of resources in specialized practice (staff shortages) and some hospital restructuring policies as important factors in specialized physicians pulling back and isolating themselves. This phenomenon can take several forms: collaboration with primary care is not seen as a priority, specialists do not feel that they need to answer to primary care, clinicians are exhausted, and the available specialized resources do not meet the clinical needs of their own patients. To this must be added ineffective communication systems; several specialists pointed out that hospitals often begin their cutbacks in communication support services.

We dont have a good system for communicating whats going on in the hospital to the family doctors. And a good hunk of that is our fault, I dont doubt it, because its a time-consuming process to track down the family doctor, you know; theyre busy, theyre not in the office when you call them, they call you back and you cant remember the specifics. You know, its a very tedious process and not very many of them come into the hospital anymore to see patients. (Internal medicine specialist)

Far from view... The notion of a certain distance appearing between the two professions was most strongly expressed by educators in the specialty disciplines. They mentioned and often deplored the fact that family physicians have pulled away from areas where they, the specialists, continue to practice. This estrangement has been as apparent in urban hospital practice settings as it has in training environments. Family physicians have progressively abandoned hospitals to practice in the community. As a result, they no longer rub elbows with medical specialists, who work first and foremost in hospitals. Indeed, specialists highly value hospital work, as hospitals are important centres of higher learning and specialized practice.

And thats whats been lost by the family doctors leaving the hospital environment. For all the time they used to see their patients in the hospital, used to assist on their own surgeries and everything, they developed relationships with specialists. They had that. (Family medicine educator)

A slightly cynical specialist added:

Their patients go to hospital, and they are the champions of continuity of care, but when their patients hit the door here, for the most part the patients dont have continuity of care. When their patient is discharged, they dont seem to pick up the continuity of care. (Specialist in inetrnal medicine)

The domino theory Participants said they had seen a shift in, a new sharing of, even confusion over the respective roles of specialists and family physicians. For the most part they attributed the change to current medical staffing shortages. They described a paradox in the form of a domino effect: specialists are leaving certain specialty areas vacant, retreating into overspecialization, while family physicians are abandoning primary care and assuming more and more of the responsibilities that

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have traditionally been the domain of specialists. But there are times when the opposite is true: specialist physicians will invade a traditional area of practice of family medicine. There is, however, one point in common: each group deplores the fact that the other is not playing its role.

I have noticed the staffing shortages. It is a situation that we have already seen in the more remote areas, but it is now spreading to other regions. The shortage causes a shift in roles: the nurse wants to become more of a clinician, family physicians want to become more specialized, and specialists want to specialize even more... (Family medicine educator) We are now in what I would qualify as a major crisis. Were putting out fires: family physicians are mainly providing specialized services because we dont have enough specialists. For example, we only have one endocrinologist for an entire territory, so family physicians are taking care of the diabetes clinics. And they do it very well; they have developed very good expertise in that area. But while they are doing that, they dont have the time to follow patients in the office. Accessibility in primary care? Its unfortunate for the patients, but they have problems finding a family physician. They cant get access as fast as we might want. (Family medicine educator) There seems to be little commitment on the part of many of the specialists to facilitating the care provided at the primary care level. The specialists are spending a lot of time doing follow-up care that probably should be handled by family doctors, and could easily be handled by family doctors, and it consumes a great deal of their time. What we need is access or consultation, new consultation. And I dont know if they do this because theyre reacting to the fact that many family physicians arent willing to follow these problems, or because there are financial incentives because its simple to do follow-up care and much more difficult to take on new patients. But thats whats needed in the system, so perhaps they need to be compensated differently, one that would take away the incentive for routine work and let family doctors do that and be available for administration. Thats what we really need. (Family physician) I think the most important group, the most important job in medicine is family practice, primary care. Not because I did it when I started out, but because thats the really important job. That has to be the sole way to integrate care, and it doesnt happen. Maybe for a variety of reasons. (Internal medicine specialist)

2.3 Collaboration can be learned! ... Really? Here again we had a consensus: collaborative practice between family physicians and medical specialists will not be possible if practitioners in each of the professions have not been trained for it. The academic community appears to be very aware of their responsibilities in this area, since all the programs we studied comply with the directives of the Royal College of Physicians and Surgeons and have objectives with respect to collaboration competencies. But setting objectives is different from meeting them, and in the case of collaborative practice, our respondents believe that this distinction persists.

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In theory, vaguely stated intentions All the programs that responded to the mail survey had established collaboration competency objectives.4 For the majority of them these objectives were institutional, meaning that the program had written its own objectives as a function of institutional needs. The majority of these objectives identified terminal competencies rather than specifying intermediate objectives that would lead to these competencies. The objectives were generally based on traditional concepts, with little in the way of innovative concepts of collaboration competencies. More specifically, if there was specific mention of collaboration with multidisciplinary teams, very few institutions made explicit reference to direct collaboration between the specialist and the family physician. Only four internal medicine programs and three programs in psychiatry listed it among their objectives. References to relationships with the family physician were usually found in the context of medical specialists responsibilities in the training of generalists rather than in a context of a collaborative relationship. The objectives therefore did not indicate notions such as community of practice, the sharing of knowledge, conflict resolution, the delegation of medical acts to other health professionals, multiprofessionalism or interprofessionalism. The objectives were often succinct with little in the way of detail, leaving one to assume that professors and residents are able to perceive clear and unequivocal expectations without precise indications of what is needed in their particular specialty. The analysis therefore revealed that educational objectives are not very explicit in terms of professional collaboration. For all intents and purposes, consultation is the only collaborative activity between a family physician and a medical specialist for which teaching has been formalized. It should nevertheless be mentioned that the physicians teaching these programs appear to be aware of these shortcomings and limitations. One of them effectively summarized the view of everyone we met: We pay lip service to collaboration. In practice, collaboration left to its own devices The residents we interviewed had not had formal experiences of collaboration between future medical specialists and future family physicians. They interact when they are on call (generally known as the junior/senior relationship). Together, they survive the training experience, this common ordeal that at least helps break down their prejudices. According to residents, professional collaboration is generally not a formal part of the clinical rotations experience, with the exception being training programs in psychiatry. When professional collaboration is explicitly discussed, it is collaboration with other professions rather than collaboration between family physicians and specialists. Collaboration is therefore learned on the job: for example, during hospital rotations. Experience varies in family medicine; the residents who spoke of being exposed to collaboration with other professionals who were doing rotations in innovative training environments. 4 Detailed results from the mail survey are presented in Table 2.

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Pointing fingers at university hospitals Where the training takes place appears to play a critical role in learning collaborative practice. Residents have the perception that collaboration with primary care is not a priority in university hospitals. Generally speaking, the family physicians we interviewed (residents and educators) were very bitter about their relationships with medical specialists in university hospitals, so bitter that they had difficulty taking some distance from the subject. In almost all the specialized rotations, family medicine residents said that they heard their specialist supervisors make offensive comments about the clinical conduct of community-based family physicians, comments often made in the presence of residents in specialized medicine. All of them said that at one point they had heard certain specialist professors denigrate their career choice.

Family medicine is not well regarded anymore, and I think a lot of it starts early. In the education system, we are taught by specialists. You dont see family physicians, you dont have any role models when you go through training. (Resident in family medicine) Specialists dont respect family doctors, you see it all the time. Were in a medical school thats meant to produce family doctors, thats the model of our medical school. But were taught totally, entirely, solely, by specialists, except probably for a month-long token visit by a family doctor. (Resident in family medicine) The family physician must be key, the central person for anyone entering the health care system. Unfortunately, this role is scorned in university hospitals because there are just too many specialists. The situation seems to be better in the regions. (Resident in family medicine)

Rotations in the regions generally seem to escape this pattern, offering positive role models to residents in both family medicine and specialized medicine:

I am in a region. I find that during a rotation, residents really have a chance to get to know and work with specialists. Here, as family physicians, we have very close contacts with the basic specialties, including surgery, pediatrics and internal medicine. Residents have the same experience when they start rotations. They have clinical responsibility for patients for example, when patients are hospitalized and if they have a problem they want to discuss, they call the specialist in internal medicine directly. The specialists in internal medicine, like all our specialists, are very open to direct contact with residents. Even in Emergency, when they want to admit a patient, they will call the specialist or the family physician directly. Even for specialty residents who do rotations here, its a good experience because they dont often have the opportunity to see this kind of teamwork between family physicians and specialists, with a case management role for the family physician and a consulting role for the specialist. For residents, the best way to learn to collaborate is to do it during their clerkship. (Family physician educator)

Not being familiar with the training of other physicians Perhaps what we have just seen in the preceding discussion is one of the factors that has led the majority of family medicine programs to pull their students out of rotations in overspecialized disciplines, deciding that this training is not appropriate. One of the consequences of this decision is that students in family medicine are mostly trained in community-based hospitals, where they do not have much contact with specialty residents. They therefore deal with specialists who have

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little contact with related university departments. The professors teaching in the residency programs of both types of discipline therefore do not often interact with each other in joint teaching projects. The result is that specialist physicians have a limited understanding of the actual training received by general practitioners, and some of them have the impression that it is training at a discount. Clearly this attitude does not foster healthy collaborative relationships.

I wouldnt have a clue as to where theyre getting trained, either in psychotherapy or social work There hasnt been a single family practitioner to come through our training program in years, not even taking it as an elective. So, to me, thats a real problem because I think family physicians do an extraordinary amount of mental health care. But I would propose that theyre really ill-trained for it. Ill go back to my first thing. I dont know if theyre trained for it. (Director of a psychiatry program) Well, they do thing