Journal of CommunityHealthVol. 1, No. 3, Spring 1976
BRIDGING THE GAPS BETWEEN DEPARTMENTS OF COMMUNITY AND FAMILY MEDICINE: THE CALGARY EXPERIENCE David Steinman, M.D., M.P.H.
ABSTRACT: Current emphasis on innovation in primary care has revealed conflicts between generalist clinicians and professionals in community medicine. Several problems are now evident in the combination of community medicine and family medicine. Three elements of a planned institutional approach to overcome problems in primary health care education at the University of Calgary, Faculty of Medicine, are discussed: the introduction of an integrated curriculum, deemphasis of departments, and a center for ambulatory care. North American medical educational institutions have evolved from the Flexnerian biomedical model to become health-care-conscious establishments that aspire to meet more fully the needs of the people they serve. At the same time, preventive medicine has moved b e y o n d strictly departmental concerns. It is now involved in overall efforts o f the faculties to seek and develop demonstrable behavioral characteristics in all graduates-behaviors that are consistent with medicine's profession o f being vitally concerned with the prevention of disease and distress. Family medicine, meantime, is striving to restore to the individual commitments that have until recently been submerged by c o m m i t m e n t s to technology. 1 These two movements, while sharing some goals and a c o m m o n interest in primary care, arise from different sources and have, in the present stage of transition, many unresolved conflicts. Prevention-minded physicians feel there are a large n u m b e r of u n m e t expectations about what medicine can do a n d what it is doing, between the needs of individuals in their homes and the capabilities of m o d e m medicine. Many of these expectations relate to primary care, and are therefore also expectations for family practice, although the whole system of medical care and the approach professionals have for the system are a part of their concern. Stewart expressed some of these claims when he described the need for a "link between family and hospital as a primary goal for the nation's health enterprises . . . . Every person who is ill or injured should have a place to go for initial entrance into the health system. He should k n o w where it is, how to obtain its services, and he should have confidence in it. ''2
Dr. Steinman is Director, Ambulatory Care Centre, Faculty of Medicine, University of Calgary,Calgary,Alberta,Canada. 205
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Complicating the needs of the individual patient, Vandervoot and Ransom point out the major medical problems of heart disease, obesity, alcoholism, drug abuse, emotional disorders, sexual problems, and many chronic medical complaints, as being essentially intractable to an individual approach. 3 Haggerty reiterates this position by claiming that improvement of the health of the population will require changing the way people live-to persuade them to modify their habits of eating, smoking, and drinking, of sleep and exercise, and their ways of handling stress. Because the modification of these habits is the goal of primary care, the skills needed to teach or change these habits should also be included in the educational programs for all primary care personnel. 4 Family medicine and c o m m u n i t y medicine have yet to agree on the priority and responsibility for the new tasks in the role of the emerging primary physician or on how this person should be educated; they have yet to establish how the disciplines might best relate to each other. To understand these conflicts and aid in the establishment of positive relationships, one must first understand the traditional, as well as current, perspectives. Historically, there has been a distinct separation between the public health and medical care sectors, s The diagnosis and treatment of acute illness became the domain of medical practitioners, who frequently ignored other aspects of comprehensive care. Public health focused on endemic and epidemic illness, focusing on group care, rather than on the individual. Jargon, role expectations, and behavior became separated. However, perceptions have changed as medical educators have become involved not only with the preparation and training of practitioners but also with the more fundamental problems of the care system itself-the distribution of both illnesses and services, the problems of health care utilization, and the quality of that care. In 1972, the objectives of the Fourth World Conference on Medical Education were (a) to develop in the participants an awareness of health needs and how these needs should influence medical education and (b) to find ways to determine these health needs, as well as ways to motivate the changes necessary in medical education to meet these needs. 6 Primary care has been reinstated as a high educational priority. The Executive Council of the Association of American Medical Colleges (AAMC) in December of 1972 identified as a major priority for the association the need to develop improved programs in education for primary care. A survey, taken by the AAMC in April of 1973, revealed that two thirds of academic medical centers were actively involved in the training of new health practitioners. Half of the institutions had developed programs for training graduates in family practice, with another 25% planning to do so. 7 There has been a growing tendency to wed the elements of these two traditional approaches, curative medicine and public health, into a third approach, s McDermott and others have proposed the use of a "managerial
Community and Family Medicine
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type" of physician in addition to clinical physicians. McDermott stated that "if we in medicine are successful in devising wholly new ways of applying our science and technology for man's benefits without losing what we have gained for the individual-if we are successful in devising teaching programs, research, and other action, based on a concept of the statistically expressed g o o d - w e will find our medical students will be ready for it. ''9 McDermott borrowed the concept of the "statistically expressed good" from C. H. Waddington who, in The Ethical Animal, argued that the greatest intellectual and moral struggle was that effort directed toward changing statistical indices, such as decreasing infant mortality and lengthening life span. He contended that "the subtle modalities of interpersonal relationships are not the kernel of the m a t t e r . . , the idea of the good . .. can hardly be expressed, except in terms of statistical parameters. ''1° A 1970s example of the Waddington approach is the Health Fields Concept of Laframboise who, through an examination of the causes and underlying factors of sickness and death in Canada, has proposed that future federal health endeavors be approached from one or more of the four broad areas of human biology, the environment, life style, and the health care organization. 1 In the late 1960s, when the intense interest in the development of primary care began, faculties had already begun to develop ways of incorporating some of these ideas. As more demands arose for both primary care and preventive medicine, the new, often small, overworked and overextended, heterogeneous community medicine departments found themselves on the front line. One can imagine a future verbal account of this period that describes the initial response of these demands: new service programs generally designed to meet the most adverse circumstances, each with its own philosophy, method of financing, and support. Meanwhile, general physicians, long away from academic halls, were sent what they perceived of as long overdue requests for aid in putting out the lack-of-primary-care fire. The generalists were surprised and confounded with the array of programs that greeted them. Having such diverse training and experiences, the newcomers often found they were unable to communicate effectively, nor was it easy to find their places in the new hierarchies. The generalists knew medical practice to be a tangled mixture of trivialities and serious ailments, of emergencies and intractable illnesses. They knew that a physician must first be able to act, to make decisions from incomplete data; he must be ready to make tentative clinical diagnoses, based on intelligent guesswork. Problem solving, clinical skills, and judgment were the attributes that must have the highest priority for fostering in the educational process. The generalists' spokesman was Francis Peabody, who said, "The secret of the care of the patient is caring for the Patient". 12 The family doctor intended to become, and remain, emotionally involved with his patients as one way of expressing his concern for their welfare.
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Thus, it is apparent that Family and Community Medicine have separate perceptions of the new physician. The image of McDermott's managerial physician is still blurred and has yet to converge with that of Peabody's caring physician. In time, will a new physician emerge to meet both sets of expectations? Many educators believe that this central issue will ultimately be resolved and are working toward that end. Curricula for family practice have been developed in several countries, including Canada, Great Britain, and the United States. 13-15 Haggerty identified the difficulties-"perhaps the most difficult dilemma faced by primary care is how to meld the often incompatible elements of science, technology, status, and autonomy on the one hand, with the equally great needs of patients for warm, humane, personalized service. . . . If the balance swings too far either way, primary care is in trouble". Haggerty feels that family practice programs must combine the difficult goals of teaching efficiency and efficacy while at the same time emphasizing the broader aspects of care for both the individual and his family within their normal environment. 4
"MARITAL PROBLEMS" Several problems can be anticipated as a consequence of the union of community medicine and family medicine at the current time. Three authors have questioned the wisdom of this "marriage of convenience". 16' 17 Problems of Nomenclature and Semantics
Debate has occurred over the meaning and implications of such departmental names as Community Medicine, Social Medicine, Primary Medical Care, and General Practice. Ellis comments on the unfortunate connotations associated with terms that relate to primary care delivery. 18 Some argue that a name is of no great importance to the people involved if the roles and relationships between members of the multidisciplinary department are clearly identified. When the activities of departments of community medicine and family practice are analyzed, however, it is doubtful that strong programs can be developed easily in each of the several areas within one department simultaneously. Family practice departments frequently express themselves as if they were the first guardians of "clinical wisdom", competing as they do with other specialties for a stake in primary care. 4, 19, 2o Seasoned clinicians who provide reliable services are seen as the entree to the community. Community medicine makes an appraisal of the medical problems of a society and an analysis of the means for solving them; these are the specific responsibilities of their teaching. Holding true to Waddington's position,
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they see no teaching activity as being accomplished until adequate attention has been paid to the problems on the upper levels of the molecule-ceI1individual-family-community-mankind and environment continuum. Therefore, being a good clinician in the traditional sense is often not good enough. The substance of c o m m u n i t y medicine curricula includes statistics, health care delivery, health care research, and epidemiology, as well as important elements from the behavioral sciences, sociology, and others (such as anthropology, human ecology, and economics). These disciplines all share c o m m o n ground with family practice in that they span disease processes and relate to the successful functionings of individuals in communitiesJ 6 Department names do have definite ramifications outside departments: legislators and the public usually equate family practitioners with primary, emergency, and personalized care that is more readily accessible, better distributed, and more compatible with their perceptions of need. Often such public demand is n o t expressed as care for "the family as a unit" or for "comprehensive care" or c o m m u n i t y medicine or "health maintenance". These terms are academic phrases that are only partially accurate translations of the more explicit needs defined by the public. 21 Problems between Clinicians and Community Health Specialists Community health specialist practitioners (i.e., the core members of that discipline-epidemiologists, health care researchers, behavioral scientists, sociologists, and others, who usually do not hold joint clinical appointments) frequently disagree with clinicians about "the proper perspective" and "the proper direction" for their c o m m o n activities. Clinicians generally feel that the "clinical horse" should clearly pull the "sociobehavioral cart". The c o m m u n i t y health specialists generally agree, but feel that the horse is not headed in the right direction-social scientists have often described the general malaise affecting the medical profession, 22 with economists pointing out the profession's reactionary response to government participation in financing. 23 Differing Expectations for Health Care Models C o m m u n i t y health has strongly supported the health center concept. Speaking for this position, Grant says "Health centers constitute the only institutional setting in ~hich effective coordination for curative and preventive services can be achieved. In them, c o m m u n i t y family health care can be adequately rendered, both to provide for promotive health services and to extend the curative services to include the social and environmental factors, included in the maintenance of health. ''24 Proponents base their expectations on teamwork, 14 a liberal use of auxiliaries, 25' 26 and a frequent reliance on team teaching. General practice physicians, concentrating on
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replicating practitioners who provide primary, emergency, and ambulant medicine do not always share these attitudes and enthusiasms. Furthermore, physicians have traditionally not had an opportunity to experience effective interdisciplinary teaching and may be unsure of the students' reaction. 27 Differing Teaching and Research Needs
Holland and Morrell focused on the needs, as well as the problems, of epidemiologists, social scientists, and general practitioners, in establishing these joint academic departments; the general practice teaching unit should not be the population laboratory in which such a composite department undertakes all research activities, since it would be too artificial a medical care situation; moreover, the epidemiologist interested in generalization needs access to a wider variety of different geographic areas and communities. 16 Donald O. Anderson, commenting on the role of health sciences centers in health care research, mentioned problems associated with interprofessional and interdisciplinary efforts. He stated that broad, system-wide studies are not usually funded, because of "inadequate conceptualization". In addition, researchers publish in disciplinary journals and tend to avoid efforts that lie outside their narrow interests. 28 One senses that future program development in the educational areas of training for primary care will relate as much to faculty strengths and government interests and funding as to firm theoretical considerations. One senses that repeated confrontations, negotiations, sharings, and trade-offs will occur around and within these two departments and all other departments involved in primary care. The lack of clarity about which departments are responsible for what will probably continue for a decade or more, as these various forces jockey for position and various proposals are implemented and evaluated. The ability to live with ambiguity and shifting boundaries will remain critical factors for all concerned. It can be assumed that institutional objectives and faculty organizational policies will become increasingly important. Conflicts must be worked out within a reasonable length of time, while projected outcomes must be kept within the limits of reasonable faculty objectives. With these assumptions in mind, the elements for a new faculty approach were implemented at Calgary.
UNIVERSITY OF CALGARY FACULTY OF MEDICINE The first class of the University of Calgary Faculty of Medicine was graduated in the spring of 1973. Various members of the faculty have described the program in other publications. 29' 3o Basically, the faculty
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relies on several approaches to encourage orderly program development: the use of an integrated curriculum, a general de-emphasis of the importance of departments, and an ambulatory care center for teaching and program development. The Integrated Curriculum In step with other curricular reforms of recent years, a student is immediately introduced to the social and physical environment that affects the daily lives of the people for whom he will care, as well as the pathophysiology of their illnesses. 31 The integrated curriculum was based on the belief that a spectrum of both normal and abnormal natural forces operates at all levels-from the molecular, through the cellular, organismal levels, to the individual, family, and community levels. The curriculum, therefore, was designed to establish an appreciation for, and recognition of, some of the problems on the various levels and to teach problem-solving skills at these levels. Undergraduate work is divided into three 1 1-month years. The first two years are spent in an introductory course of ten weeks, a continuity course, and body systems courses (including the musculoskeletal, cardiovascular-respiratory, renal-electrolyte, and so forth), as well as both block and horizontal electives. The horizontal elective begins in January of the first year and continues through to the end of the second year. A fourth course of study throughout these first two years is a tutorial for independent study. The third year is spent in.the clinical clerkship. The continuity course, in which a student spends time the first two years, is a major area for community medicine input and has five themes: (a) integration with the systems courses; (b) medical-social issues; (c) growth and development; (d) primary health care; and (e) professional skills related to patients in communities. Students spend 8 to 12 hours per week on the course. All five themes are incorporated throughout, and each theme individually may be expressed in a n u m b e r of curriculum units. De-emphasis of Departments
Much has been written about the role of departments and their contribution, or lack of contribution, to institutional goals. 3z-3s The University of Calgary Faculty of Medicine designers, in planning all activities to support interrelationships and to discourage the disregard of the continuum, labeled various discipline groups as Divisions. Salary lines are controlled by the dean. Support staff and employees are either university or Trust Fund employees. The faculty is governed by a Faculty Council, which in turn appoints standing committees, including a Committee on Medical Education, a Committee on Research, and an Ambulatory Care Center Committee. The
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Executive Faculty Council is chaired by the dean and is otherwise made up of elected members. Division heads make no curriculum decisions; the faculty, and not the divisions, have overall control of the content and milieu of the student experience. Division heads do recruit and assist, and defend, their division members in making priorities for their teaching, research, and practice efforts. Ambulatory Care Center More attention will be given to education in ambulatory care (primary, comprehensive care) . . . this will mean much more cooperation or integrated relationships, through affiliation, between medical schools, regional and community hospitals, and c o m m u n i t y health centers and clinics. As a result, one might expect from to-morrow's doctors a restored concern for humane considerations and a "new balance between the elements of individual and c o m m u n i t y health needs. ''34
The faculty established the Ambulatory Care Center within the Health Sciences Center in an effort to reflect several clinical and social purposes and needs, namely: (a) to provide a model ambulatory care unit for the education and training of students of the health sciences; (b) to create a comprehensive preventive-therapeutic-rehabilitative service complex capable of providing comprehensive care for a carefully determined number of families, carrying out research in preventive and c o m m u n i t y services, making the results available to the population of Southern Alberta, and serving as a referral center in selected specialty fields for the same population. 3° Methods of meeting these objectives included designing a unit in which it is possible to bring together in geographic proximity each of the separate elements serving the community. The importance of continuity of care and viewing the sick person as part of a family unit is stressed. Due consideration is given to the application of preventive medicine and to the importance of social and emotional factors in disease. The importance of group efforts of full-time staff and consultants in care and teaching is demonstrated. Progressive patient-care units in conjunction with the adjacent Foothills Hospital are provided. Four important activities to be included in the Ambulatory Care Center are: 1. Medical care-ambulatory patients served by the Faculty of Medicine. 2. Teaching-essential teaching functions will be centered in the unit, including the student's first instruction in clinical medicine in the Family Practice Unit and his final clinical experience in the clinical clerkship. In addition, extensive graduate training in the Ambulatory Care Center was planned.
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3. Research-some of the medical school's most important research will take place in the Ambulatory Care Center. 4. Community service-it is expected that this Ambulatory Care Center will serve as a truly comprehensive clinic. This will require close association with all c o m m u n i t y health and welfare agencies. In this way the student may observe and participate in the team approach to the solution of individual and c o m m u n i t y health problems. The University of Calgary's Health Sciences Center's Ambulatory Care Center is a clinic that includes a group practice of full-time and part-time faculty physicians in family and consulting clinical practices and multidiscipline programs in community services and special clinics. The center has important objectives for medical education and health care research. The Ambulatory Care Center is one of five separate units that make up the ambulatory care facilities of the University of Calgary Faculty of Medicine. Each of these units has been designed with educational and research objectives and includes the Outpatient Psychiatric Unit of the Foothills Hospital, the Calgary General Hospital's Medical Center, the Cochrane Clinic, and the Stoney Health Center. These clinics are subject to various degrees of regulation by the University Faculty of Medicine. Augmenting the teaching facilities are a large number of private offices (through the courtesy of part-time faculty members) and general and special hospital facilities in Calgary and a wide area of the province and adjacent portions of British Columbia. Future sites for ambulatory care teaching will include the Alberta Children's Hospital's Diagnostic Assessment and Treatment Center and the Holy Cross Hospital's affiliated Family Medicine Residency program. The term Faculty Ambulatory Care Facilities applies to the several clinics designed especially for educational and research purposes. Ambulatory Care Center Facilities The basic clinic suite for b o t h the family practice unit and the consultant unit houses several physicians together, with office space for the nurse-in-the-extended-role, the social worker, student offices, examining rooms and seminar rooms, audiovisual facilities, rooms for patient education, group therapy, and observation liberally interspaced. The physical layout provides administrative, family practice, laboratory, and social services on the first floor, with consultant services, including pediatric, psychiatric, obstetric and gynecological, internal medicine, surgical, and community health science facilities on the floor above. The community health science area serves as the research unit and presently includes a biostatistical as well as a demographic laboratory. Current interdisciplinary programs within this space include wellchild care clinics and a "Trym-Gym" for overweight adults in Family
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Practice, and a High Risk Pregnancy Clinic, a Sexuality Clinic, a Family Therapy Clinic, and a Crisis Service in the consultant area. Our planning reflects our shared belief that a medical school is: justified in educating future professionals only if it can project itself into the future: 1) by engaging in patient care research with primary emphasis on the continuing needs--social, psychological, and biologic a l - o f the ambulant person; 2) bY conducting research in the learning process of the student in order to discover how to prepare him for social responsibility as well as for intellectual and professional growth; and 3) by constituting itself as a research laboratory for experimentation in the organization o f health and medical services, with special emphasis on professional and specialty roles in the delivery of comprehensive health care. 36 The emphasis on ambulatory care in the student's learning experience, the design of the Ambulatory Care Centre for education as well as service and research, and the development of c o m m u n i t y teaching units which are as carefully developed as those of the teaching hospital, will enhance the major objectives of this developing medical school. 3°
These plans were written in the late 1960s. There have been some modifications: the basic clinical suites were functionally modified by the occupants; the public health nurse and the social worker are not uniformly present in the family practice suites; each separate element for care has not yet been brought into geographic p r o x i m i t y - t h e Foothills Hospital, the Faculty of Medicine, and the Community are continuing to plan these developments. Nevertheless, the structure and opportunity exist and are being actively pursued by design and effort.
REFERENCES 1. McWhinney IR: Family medicine in perspective. N Engl J Med 293:176-I 81, 1975. 2. Stewart WH: Medical education and the community. Perspect Biol Med: 462--470. Spring 1967. 3. Vandervoot HE, Ransom DC: Undergraduate education in family medicine. J Med Educ 48: 158-165, 1973. 4. Haggerty RJ: Graduate physician training in primary care. J Med Educ 49:840, 1974. 5. Freymann JG: Medicine's great schism: Prevention versus cure, an historical interpretation. Med Care 13:525-536, 1975. 6. Editorial, B r ] Med Educ 6:262-3, 1972. 7. Schroeder, SA, Wemer SM, Piemme TE: Primary care in the academic medical centers: A report of a survey of the AAMC. J Med Educ 49: 823-832, 1974. 8. Ramaligaswami V: Unfulfilled expectations and the third approach. Br J Med Educ 2: 246--248, 1968. 9. McDermott W: Environmental factors bearing on medical education. J Med Educ 41(part 2): 161, 1966. 10. Waddington CH: The Ethical Animal Chicago, University of Chicago Press, 1967. 11. Laframboise HL: Healtla policy, breaking it down into more manageable segments. Can Med Assoc J 108:388--393, 1973. 12. Peabody FW: The caxe of the patient. JAMA 88:877-882, 1927. 13. A Manual on Training in Family Medicine. Willodale, Ontario: The College of Family Physicians of Canada, 1967. 14. Royal College of General Practitioners: The Future General Practitioner. Travistock Square, London, B.M.A. House, 1972.
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15. Albert JJ, Chamey E: The Education o f Physicians f o r Primary Care. Rockville, Md: National Center for Health Services Research and Development, Department of Health, Education, and Welfare, in press. 16. Holland WW, Morrell DC: A marriage of convenience? B r J Med Educ 6:121-124, 1972. 17. Buck C: Preventive medicine and family medicine in the medical school. Can Med Assoc J 103: 943-944, 1970. 18. Ellis J: The future teaching of general practice. Br ] Med Educ 3:23-27, 1969. 19. Ingelfinger FJ: League for beleaguered internists, editorial. N Engl J Med 292: 589-590, 1975. 20. Angelin CS, Laski B, McKendry JBJ: Letter, The Medical Post 11, March 1975. 21. Pellegrino ED: Expectations for family medicine, editorial. J M e d Educ 47:356--357, 1972. 22. Ferguson RS: The roles of medicine and social science in the future health services of Britain. B r J Med Educ 4:158-163, 1970. 23. Blishen BR: Doctors and Doctrines. London, Oxford University Press, 1970. 24. Seipp C (ed): Health Care for the Community, Selected Papers o f Dr. John B. Grant. The American Journal of Hygiene Monograph Series, No. 21. Baltimore,Johns Hopkins Press, 1963. P 106. 25. Baker C: What's different about family medicine? J Med Educ 49: 229-235, 1974. 26. Greenfield HI: Allied Health Manpower: Trends and Prospects. New York, Columbia University Press, 1969. 27. Schoenberg B, Pettit H, Cart AC: Teaching Psychosocial Aspects o f Patient Care. New York, Columbia University Press, 1968. 28. Larsen DE, Love EJ: Health Care Research, A Symposium. Calgary, Canada, University of Calgary Press, 1974. P 23. 29. Cochrane WA: Philosophy and program for medical education at the University of Calgary Faculty of Medicine. Can Med Assoc J 98:500--505, 1968. 30. Dickson AD, Read JH, Dawson, JW: Planning for medical eHucation at the University of Calgary Faculty of Medicine. Can Med Assoc J 100:665-669, 1969. 31. Ramalingaswami V: Factors influencing the development of a curriculum. Br J Med Educ 1: 251-254, 1967. 32. Lee PR: A tiger by the tail? The governance of the academic health sciences center. J M e d Educ 48:27-39, 1973. 33. Simpson MA: Medical E d u c a t i o n - A Critical Approach. London, Butterworth, 1972. 34. Prywes M: A look to the future. B r J Med Educ 6:264-267, 1972. 35. Purcell E (ed): World Trends in Medical Education. Baltimore, Johns Hopkins Press, 1971. 36. Evans LJ: Base lines of medical center education. A n n N Y A c a d Sci 128:633--40, 1965.
BRIDGING THE GAPS BETWEEN DEPARTMENTS OF COMMUNITY AND FAMILY MEDICINE: THE CALGARY EXPERIENCE David Steinman, M.D., M.P.H.
ABSTRACT: Current emphasis on innovation in primary care has revealed conflicts between generalist clinicians and professionals in community medicine. Several problems are now evident in the combination of community medicine and family medicine. Three elements of a planned institutional approach to overcome problems in primary health care education at the University of Calgary, Faculty of Medicine, are discussed: the introduction of an integrated curriculum, deemphasis of departments, and a center for ambulatory care. North American medical educational institutions have evolved from the Flexnerian biomedical model to become health-care-conscious establishments that aspire to meet more fully the needs of the people they serve. At the same time, preventive medicine has moved b e y o n d strictly departmental concerns. It is now involved in overall efforts o f the faculties to seek and develop demonstrable behavioral characteristics in all graduates-behaviors that are consistent with medicine's profession o f being vitally concerned with the prevention of disease and distress. Family medicine, meantime, is striving to restore to the individual commitments that have until recently been submerged by c o m m i t m e n t s to technology. 1 These two movements, while sharing some goals and a c o m m o n interest in primary care, arise from different sources and have, in the present stage of transition, many unresolved conflicts. Prevention-minded physicians feel there are a large n u m b e r of u n m e t expectations about what medicine can do a n d what it is doing, between the needs of individuals in their homes and the capabilities of m o d e m medicine. Many of these expectations relate to primary care, and are therefore also expectations for family practice, although the whole system of medical care and the approach professionals have for the system are a part of their concern. Stewart expressed some of these claims when he described the need for a "link between family and hospital as a primary goal for the nation's health enterprises . . . . Every person who is ill or injured should have a place to go for initial entrance into the health system. He should k n o w where it is, how to obtain its services, and he should have confidence in it. ''2
Dr. Steinman is Director, Ambulatory Care Centre, Faculty of Medicine, University of Calgary,Calgary,Alberta,Canada. 205
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JOURNAL OF COMMUNITY HEALTH
Complicating the needs of the individual patient, Vandervoot and Ransom point out the major medical problems of heart disease, obesity, alcoholism, drug abuse, emotional disorders, sexual problems, and many chronic medical complaints, as being essentially intractable to an individual approach. 3 Haggerty reiterates this position by claiming that improvement of the health of the population will require changing the way people live-to persuade them to modify their habits of eating, smoking, and drinking, of sleep and exercise, and their ways of handling stress. Because the modification of these habits is the goal of primary care, the skills needed to teach or change these habits should also be included in the educational programs for all primary care personnel. 4 Family medicine and c o m m u n i t y medicine have yet to agree on the priority and responsibility for the new tasks in the role of the emerging primary physician or on how this person should be educated; they have yet to establish how the disciplines might best relate to each other. To understand these conflicts and aid in the establishment of positive relationships, one must first understand the traditional, as well as current, perspectives. Historically, there has been a distinct separation between the public health and medical care sectors, s The diagnosis and treatment of acute illness became the domain of medical practitioners, who frequently ignored other aspects of comprehensive care. Public health focused on endemic and epidemic illness, focusing on group care, rather than on the individual. Jargon, role expectations, and behavior became separated. However, perceptions have changed as medical educators have become involved not only with the preparation and training of practitioners but also with the more fundamental problems of the care system itself-the distribution of both illnesses and services, the problems of health care utilization, and the quality of that care. In 1972, the objectives of the Fourth World Conference on Medical Education were (a) to develop in the participants an awareness of health needs and how these needs should influence medical education and (b) to find ways to determine these health needs, as well as ways to motivate the changes necessary in medical education to meet these needs. 6 Primary care has been reinstated as a high educational priority. The Executive Council of the Association of American Medical Colleges (AAMC) in December of 1972 identified as a major priority for the association the need to develop improved programs in education for primary care. A survey, taken by the AAMC in April of 1973, revealed that two thirds of academic medical centers were actively involved in the training of new health practitioners. Half of the institutions had developed programs for training graduates in family practice, with another 25% planning to do so. 7 There has been a growing tendency to wed the elements of these two traditional approaches, curative medicine and public health, into a third approach, s McDermott and others have proposed the use of a "managerial
Community and Family Medicine
207
type" of physician in addition to clinical physicians. McDermott stated that "if we in medicine are successful in devising wholly new ways of applying our science and technology for man's benefits without losing what we have gained for the individual-if we are successful in devising teaching programs, research, and other action, based on a concept of the statistically expressed g o o d - w e will find our medical students will be ready for it. ''9 McDermott borrowed the concept of the "statistically expressed good" from C. H. Waddington who, in The Ethical Animal, argued that the greatest intellectual and moral struggle was that effort directed toward changing statistical indices, such as decreasing infant mortality and lengthening life span. He contended that "the subtle modalities of interpersonal relationships are not the kernel of the m a t t e r . . , the idea of the good . .. can hardly be expressed, except in terms of statistical parameters. ''1° A 1970s example of the Waddington approach is the Health Fields Concept of Laframboise who, through an examination of the causes and underlying factors of sickness and death in Canada, has proposed that future federal health endeavors be approached from one or more of the four broad areas of human biology, the environment, life style, and the health care organization. 1 In the late 1960s, when the intense interest in the development of primary care began, faculties had already begun to develop ways of incorporating some of these ideas. As more demands arose for both primary care and preventive medicine, the new, often small, overworked and overextended, heterogeneous community medicine departments found themselves on the front line. One can imagine a future verbal account of this period that describes the initial response of these demands: new service programs generally designed to meet the most adverse circumstances, each with its own philosophy, method of financing, and support. Meanwhile, general physicians, long away from academic halls, were sent what they perceived of as long overdue requests for aid in putting out the lack-of-primary-care fire. The generalists were surprised and confounded with the array of programs that greeted them. Having such diverse training and experiences, the newcomers often found they were unable to communicate effectively, nor was it easy to find their places in the new hierarchies. The generalists knew medical practice to be a tangled mixture of trivialities and serious ailments, of emergencies and intractable illnesses. They knew that a physician must first be able to act, to make decisions from incomplete data; he must be ready to make tentative clinical diagnoses, based on intelligent guesswork. Problem solving, clinical skills, and judgment were the attributes that must have the highest priority for fostering in the educational process. The generalists' spokesman was Francis Peabody, who said, "The secret of the care of the patient is caring for the Patient". 12 The family doctor intended to become, and remain, emotionally involved with his patients as one way of expressing his concern for their welfare.
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Thus, it is apparent that Family and Community Medicine have separate perceptions of the new physician. The image of McDermott's managerial physician is still blurred and has yet to converge with that of Peabody's caring physician. In time, will a new physician emerge to meet both sets of expectations? Many educators believe that this central issue will ultimately be resolved and are working toward that end. Curricula for family practice have been developed in several countries, including Canada, Great Britain, and the United States. 13-15 Haggerty identified the difficulties-"perhaps the most difficult dilemma faced by primary care is how to meld the often incompatible elements of science, technology, status, and autonomy on the one hand, with the equally great needs of patients for warm, humane, personalized service. . . . If the balance swings too far either way, primary care is in trouble". Haggerty feels that family practice programs must combine the difficult goals of teaching efficiency and efficacy while at the same time emphasizing the broader aspects of care for both the individual and his family within their normal environment. 4
"MARITAL PROBLEMS" Several problems can be anticipated as a consequence of the union of community medicine and family medicine at the current time. Three authors have questioned the wisdom of this "marriage of convenience". 16' 17 Problems of Nomenclature and Semantics
Debate has occurred over the meaning and implications of such departmental names as Community Medicine, Social Medicine, Primary Medical Care, and General Practice. Ellis comments on the unfortunate connotations associated with terms that relate to primary care delivery. 18 Some argue that a name is of no great importance to the people involved if the roles and relationships between members of the multidisciplinary department are clearly identified. When the activities of departments of community medicine and family practice are analyzed, however, it is doubtful that strong programs can be developed easily in each of the several areas within one department simultaneously. Family practice departments frequently express themselves as if they were the first guardians of "clinical wisdom", competing as they do with other specialties for a stake in primary care. 4, 19, 2o Seasoned clinicians who provide reliable services are seen as the entree to the community. Community medicine makes an appraisal of the medical problems of a society and an analysis of the means for solving them; these are the specific responsibilities of their teaching. Holding true to Waddington's position,
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they see no teaching activity as being accomplished until adequate attention has been paid to the problems on the upper levels of the molecule-ceI1individual-family-community-mankind and environment continuum. Therefore, being a good clinician in the traditional sense is often not good enough. The substance of c o m m u n i t y medicine curricula includes statistics, health care delivery, health care research, and epidemiology, as well as important elements from the behavioral sciences, sociology, and others (such as anthropology, human ecology, and economics). These disciplines all share c o m m o n ground with family practice in that they span disease processes and relate to the successful functionings of individuals in communitiesJ 6 Department names do have definite ramifications outside departments: legislators and the public usually equate family practitioners with primary, emergency, and personalized care that is more readily accessible, better distributed, and more compatible with their perceptions of need. Often such public demand is n o t expressed as care for "the family as a unit" or for "comprehensive care" or c o m m u n i t y medicine or "health maintenance". These terms are academic phrases that are only partially accurate translations of the more explicit needs defined by the public. 21 Problems between Clinicians and Community Health Specialists Community health specialist practitioners (i.e., the core members of that discipline-epidemiologists, health care researchers, behavioral scientists, sociologists, and others, who usually do not hold joint clinical appointments) frequently disagree with clinicians about "the proper perspective" and "the proper direction" for their c o m m o n activities. Clinicians generally feel that the "clinical horse" should clearly pull the "sociobehavioral cart". The c o m m u n i t y health specialists generally agree, but feel that the horse is not headed in the right direction-social scientists have often described the general malaise affecting the medical profession, 22 with economists pointing out the profession's reactionary response to government participation in financing. 23 Differing Expectations for Health Care Models C o m m u n i t y health has strongly supported the health center concept. Speaking for this position, Grant says "Health centers constitute the only institutional setting in ~hich effective coordination for curative and preventive services can be achieved. In them, c o m m u n i t y family health care can be adequately rendered, both to provide for promotive health services and to extend the curative services to include the social and environmental factors, included in the maintenance of health. ''24 Proponents base their expectations on teamwork, 14 a liberal use of auxiliaries, 25' 26 and a frequent reliance on team teaching. General practice physicians, concentrating on
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replicating practitioners who provide primary, emergency, and ambulant medicine do not always share these attitudes and enthusiasms. Furthermore, physicians have traditionally not had an opportunity to experience effective interdisciplinary teaching and may be unsure of the students' reaction. 27 Differing Teaching and Research Needs
Holland and Morrell focused on the needs, as well as the problems, of epidemiologists, social scientists, and general practitioners, in establishing these joint academic departments; the general practice teaching unit should not be the population laboratory in which such a composite department undertakes all research activities, since it would be too artificial a medical care situation; moreover, the epidemiologist interested in generalization needs access to a wider variety of different geographic areas and communities. 16 Donald O. Anderson, commenting on the role of health sciences centers in health care research, mentioned problems associated with interprofessional and interdisciplinary efforts. He stated that broad, system-wide studies are not usually funded, because of "inadequate conceptualization". In addition, researchers publish in disciplinary journals and tend to avoid efforts that lie outside their narrow interests. 28 One senses that future program development in the educational areas of training for primary care will relate as much to faculty strengths and government interests and funding as to firm theoretical considerations. One senses that repeated confrontations, negotiations, sharings, and trade-offs will occur around and within these two departments and all other departments involved in primary care. The lack of clarity about which departments are responsible for what will probably continue for a decade or more, as these various forces jockey for position and various proposals are implemented and evaluated. The ability to live with ambiguity and shifting boundaries will remain critical factors for all concerned. It can be assumed that institutional objectives and faculty organizational policies will become increasingly important. Conflicts must be worked out within a reasonable length of time, while projected outcomes must be kept within the limits of reasonable faculty objectives. With these assumptions in mind, the elements for a new faculty approach were implemented at Calgary.
UNIVERSITY OF CALGARY FACULTY OF MEDICINE The first class of the University of Calgary Faculty of Medicine was graduated in the spring of 1973. Various members of the faculty have described the program in other publications. 29' 3o Basically, the faculty
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relies on several approaches to encourage orderly program development: the use of an integrated curriculum, a general de-emphasis of the importance of departments, and an ambulatory care center for teaching and program development. The Integrated Curriculum In step with other curricular reforms of recent years, a student is immediately introduced to the social and physical environment that affects the daily lives of the people for whom he will care, as well as the pathophysiology of their illnesses. 31 The integrated curriculum was based on the belief that a spectrum of both normal and abnormal natural forces operates at all levels-from the molecular, through the cellular, organismal levels, to the individual, family, and community levels. The curriculum, therefore, was designed to establish an appreciation for, and recognition of, some of the problems on the various levels and to teach problem-solving skills at these levels. Undergraduate work is divided into three 1 1-month years. The first two years are spent in an introductory course of ten weeks, a continuity course, and body systems courses (including the musculoskeletal, cardiovascular-respiratory, renal-electrolyte, and so forth), as well as both block and horizontal electives. The horizontal elective begins in January of the first year and continues through to the end of the second year. A fourth course of study throughout these first two years is a tutorial for independent study. The third year is spent in.the clinical clerkship. The continuity course, in which a student spends time the first two years, is a major area for community medicine input and has five themes: (a) integration with the systems courses; (b) medical-social issues; (c) growth and development; (d) primary health care; and (e) professional skills related to patients in communities. Students spend 8 to 12 hours per week on the course. All five themes are incorporated throughout, and each theme individually may be expressed in a n u m b e r of curriculum units. De-emphasis of Departments
Much has been written about the role of departments and their contribution, or lack of contribution, to institutional goals. 3z-3s The University of Calgary Faculty of Medicine designers, in planning all activities to support interrelationships and to discourage the disregard of the continuum, labeled various discipline groups as Divisions. Salary lines are controlled by the dean. Support staff and employees are either university or Trust Fund employees. The faculty is governed by a Faculty Council, which in turn appoints standing committees, including a Committee on Medical Education, a Committee on Research, and an Ambulatory Care Center Committee. The
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Executive Faculty Council is chaired by the dean and is otherwise made up of elected members. Division heads make no curriculum decisions; the faculty, and not the divisions, have overall control of the content and milieu of the student experience. Division heads do recruit and assist, and defend, their division members in making priorities for their teaching, research, and practice efforts. Ambulatory Care Center More attention will be given to education in ambulatory care (primary, comprehensive care) . . . this will mean much more cooperation or integrated relationships, through affiliation, between medical schools, regional and community hospitals, and c o m m u n i t y health centers and clinics. As a result, one might expect from to-morrow's doctors a restored concern for humane considerations and a "new balance between the elements of individual and c o m m u n i t y health needs. ''34
The faculty established the Ambulatory Care Center within the Health Sciences Center in an effort to reflect several clinical and social purposes and needs, namely: (a) to provide a model ambulatory care unit for the education and training of students of the health sciences; (b) to create a comprehensive preventive-therapeutic-rehabilitative service complex capable of providing comprehensive care for a carefully determined number of families, carrying out research in preventive and c o m m u n i t y services, making the results available to the population of Southern Alberta, and serving as a referral center in selected specialty fields for the same population. 3° Methods of meeting these objectives included designing a unit in which it is possible to bring together in geographic proximity each of the separate elements serving the community. The importance of continuity of care and viewing the sick person as part of a family unit is stressed. Due consideration is given to the application of preventive medicine and to the importance of social and emotional factors in disease. The importance of group efforts of full-time staff and consultants in care and teaching is demonstrated. Progressive patient-care units in conjunction with the adjacent Foothills Hospital are provided. Four important activities to be included in the Ambulatory Care Center are: 1. Medical care-ambulatory patients served by the Faculty of Medicine. 2. Teaching-essential teaching functions will be centered in the unit, including the student's first instruction in clinical medicine in the Family Practice Unit and his final clinical experience in the clinical clerkship. In addition, extensive graduate training in the Ambulatory Care Center was planned.
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3. Research-some of the medical school's most important research will take place in the Ambulatory Care Center. 4. Community service-it is expected that this Ambulatory Care Center will serve as a truly comprehensive clinic. This will require close association with all c o m m u n i t y health and welfare agencies. In this way the student may observe and participate in the team approach to the solution of individual and c o m m u n i t y health problems. The University of Calgary's Health Sciences Center's Ambulatory Care Center is a clinic that includes a group practice of full-time and part-time faculty physicians in family and consulting clinical practices and multidiscipline programs in community services and special clinics. The center has important objectives for medical education and health care research. The Ambulatory Care Center is one of five separate units that make up the ambulatory care facilities of the University of Calgary Faculty of Medicine. Each of these units has been designed with educational and research objectives and includes the Outpatient Psychiatric Unit of the Foothills Hospital, the Calgary General Hospital's Medical Center, the Cochrane Clinic, and the Stoney Health Center. These clinics are subject to various degrees of regulation by the University Faculty of Medicine. Augmenting the teaching facilities are a large number of private offices (through the courtesy of part-time faculty members) and general and special hospital facilities in Calgary and a wide area of the province and adjacent portions of British Columbia. Future sites for ambulatory care teaching will include the Alberta Children's Hospital's Diagnostic Assessment and Treatment Center and the Holy Cross Hospital's affiliated Family Medicine Residency program. The term Faculty Ambulatory Care Facilities applies to the several clinics designed especially for educational and research purposes. Ambulatory Care Center Facilities The basic clinic suite for b o t h the family practice unit and the consultant unit houses several physicians together, with office space for the nurse-in-the-extended-role, the social worker, student offices, examining rooms and seminar rooms, audiovisual facilities, rooms for patient education, group therapy, and observation liberally interspaced. The physical layout provides administrative, family practice, laboratory, and social services on the first floor, with consultant services, including pediatric, psychiatric, obstetric and gynecological, internal medicine, surgical, and community health science facilities on the floor above. The community health science area serves as the research unit and presently includes a biostatistical as well as a demographic laboratory. Current interdisciplinary programs within this space include wellchild care clinics and a "Trym-Gym" for overweight adults in Family
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Practice, and a High Risk Pregnancy Clinic, a Sexuality Clinic, a Family Therapy Clinic, and a Crisis Service in the consultant area. Our planning reflects our shared belief that a medical school is: justified in educating future professionals only if it can project itself into the future: 1) by engaging in patient care research with primary emphasis on the continuing needs--social, psychological, and biologic a l - o f the ambulant person; 2) bY conducting research in the learning process of the student in order to discover how to prepare him for social responsibility as well as for intellectual and professional growth; and 3) by constituting itself as a research laboratory for experimentation in the organization o f health and medical services, with special emphasis on professional and specialty roles in the delivery of comprehensive health care. 36 The emphasis on ambulatory care in the student's learning experience, the design of the Ambulatory Care Centre for education as well as service and research, and the development of c o m m u n i t y teaching units which are as carefully developed as those of the teaching hospital, will enhance the major objectives of this developing medical school. 3°
These plans were written in the late 1960s. There have been some modifications: the basic clinical suites were functionally modified by the occupants; the public health nurse and the social worker are not uniformly present in the family practice suites; each separate element for care has not yet been brought into geographic p r o x i m i t y - t h e Foothills Hospital, the Faculty of Medicine, and the Community are continuing to plan these developments. Nevertheless, the structure and opportunity exist and are being actively pursued by design and effort.
REFERENCES 1. McWhinney IR: Family medicine in perspective. N Engl J Med 293:176-I 81, 1975. 2. Stewart WH: Medical education and the community. Perspect Biol Med: 462--470. Spring 1967. 3. Vandervoot HE, Ransom DC: Undergraduate education in family medicine. J Med Educ 48: 158-165, 1973. 4. Haggerty RJ: Graduate physician training in primary care. J Med Educ 49:840, 1974. 5. Freymann JG: Medicine's great schism: Prevention versus cure, an historical interpretation. Med Care 13:525-536, 1975. 6. Editorial, B r ] Med Educ 6:262-3, 1972. 7. Schroeder, SA, Wemer SM, Piemme TE: Primary care in the academic medical centers: A report of a survey of the AAMC. J Med Educ 49: 823-832, 1974. 8. Ramaligaswami V: Unfulfilled expectations and the third approach. Br J Med Educ 2: 246--248, 1968. 9. McDermott W: Environmental factors bearing on medical education. J Med Educ 41(part 2): 161, 1966. 10. Waddington CH: The Ethical Animal Chicago, University of Chicago Press, 1967. 11. Laframboise HL: Healtla policy, breaking it down into more manageable segments. Can Med Assoc J 108:388--393, 1973. 12. Peabody FW: The caxe of the patient. JAMA 88:877-882, 1927. 13. A Manual on Training in Family Medicine. Willodale, Ontario: The College of Family Physicians of Canada, 1967. 14. Royal College of General Practitioners: The Future General Practitioner. Travistock Square, London, B.M.A. House, 1972.
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15. Albert JJ, Chamey E: The Education o f Physicians f o r Primary Care. Rockville, Md: National Center for Health Services Research and Development, Department of Health, Education, and Welfare, in press. 16. Holland WW, Morrell DC: A marriage of convenience? B r J Med Educ 6:121-124, 1972. 17. Buck C: Preventive medicine and family medicine in the medical school. Can Med Assoc J 103: 943-944, 1970. 18. Ellis J: The future teaching of general practice. Br ] Med Educ 3:23-27, 1969. 19. Ingelfinger FJ: League for beleaguered internists, editorial. N Engl J Med 292: 589-590, 1975. 20. Angelin CS, Laski B, McKendry JBJ: Letter, The Medical Post 11, March 1975. 21. Pellegrino ED: Expectations for family medicine, editorial. J M e d Educ 47:356--357, 1972. 22. Ferguson RS: The roles of medicine and social science in the future health services of Britain. B r J Med Educ 4:158-163, 1970. 23. Blishen BR: Doctors and Doctrines. London, Oxford University Press, 1970. 24. Seipp C (ed): Health Care for the Community, Selected Papers o f Dr. John B. Grant. The American Journal of Hygiene Monograph Series, No. 21. Baltimore,Johns Hopkins Press, 1963. P 106. 25. Baker C: What's different about family medicine? J Med Educ 49: 229-235, 1974. 26. Greenfield HI: Allied Health Manpower: Trends and Prospects. New York, Columbia University Press, 1969. 27. Schoenberg B, Pettit H, Cart AC: Teaching Psychosocial Aspects o f Patient Care. New York, Columbia University Press, 1968. 28. Larsen DE, Love EJ: Health Care Research, A Symposium. Calgary, Canada, University of Calgary Press, 1974. P 23. 29. Cochrane WA: Philosophy and program for medical education at the University of Calgary Faculty of Medicine. Can Med Assoc J 98:500--505, 1968. 30. Dickson AD, Read JH, Dawson, JW: Planning for medical eHucation at the University of Calgary Faculty of Medicine. Can Med Assoc J 100:665-669, 1969. 31. Ramalingaswami V: Factors influencing the development of a curriculum. Br J Med Educ 1: 251-254, 1967. 32. Lee PR: A tiger by the tail? The governance of the academic health sciences center. J M e d Educ 48:27-39, 1973. 33. Simpson MA: Medical E d u c a t i o n - A Critical Approach. London, Butterworth, 1972. 34. Prywes M: A look to the future. B r J Med Educ 6:264-267, 1972. 35. Purcell E (ed): World Trends in Medical Education. Baltimore, Johns Hopkins Press, 1971. 36. Evans LJ: Base lines of medical center education. A n n N Y A c a d Sci 128:633--40, 1965.
