The family doctor in Canada. Part VIII: the way ahead By David Woods Lalonde has devoted a book, "A New Perspective on the We have seen, in this series, that family medicine is alive Health of Canadians", to this very topic. and well in Canada. All but one of the medical schools and I am sure he would probably be His concern have departments or divisions of family medicine; the the first to admit it is not entirely altruistic. Health ratio of GPs to specialists appears to have levelled out at has become a pretty expensive business in Canada conabout 50-50; undergraduate, postgraduate and continuing education programs for family doctors have become in¬ suming some 1% of our gross national product and ac¬ creasingly relevant and sophisticated; and family practice counting for about $7 billion in annual expenditures. For those who pick it up, that sort of tab can be rather is enjoying renewed status in the medical profession, among medical students and with governments and the public. daunting; there seems to be a consensus that the best hope of cutting it back, or at least holding the line, lies in Where do we go from here? preventive medicine a field in which the general prac¬ titioner could be preeminent. In a guest editorial in The Annals of General Practice The GP of the future, then, will likely be concerned (now Australian Family Physician) in July 1971, I wrote much more than he is today with health maintenance. about the future of family medicine, noting that the attractiveness of the assignment was that if my predictions Existing trends strongly suggest that he will practise pri¬ turned out to be right I should take great pains to remind mary, continuing and comprehensive care within a multireaders of that fact; if they were wrong, those readers specialty group that will include the services of such allied health personnel as nurse practitioners, would have forgotten what I predicted psychologists and social workers. It is anyway. This is the final artfcle in an But the editorial was really less a possible that he will do so under a series by David Woods on matter of outright prediction than a for tice in Canada. Requests reprints payment mechanism that may embrace fee for service, salary and capitation, look at changes and trends and needs of the series should be addressed to the CMA Department of Comimmicasome attempt to plot the dotted line depending on the service rendered. Curbs recently introduced on MD rions, Box 8650, 1867 Alta Vista Dr. after the solid one has ended. The speed of change, it said, is best immigration tell us that the Canadian GP of the future will be much more illustrated by speed itself: "A century likely to have trained in Canada, and that the percentage ago, man could travel no faster than 50 or 60 miles an of foreign-trained family doctors (now running at about hour; 30 years ago he could fly at 400 miles an hour; today one third of the total) will decrease sharply. he can travel at 18 000 miles an hour". Medical science and technology have speeded up just Looking at the present attrition rate among GPs, we can also fairly safely assume that aptitude testing of candidates as dramatically: the sum total of medical knowledge is for this branch of medicine will play its part. We already said to be doubling every 10 years, and 90% of all the know much more than we did about the kind of people scientists who ever lived are working today. who make good "people doctors", and to this knowledge Other changes will affect future patterns of practice: will be added information about the needs of the com¬ increases in population; increases in lifespan; elimination or control of diseases once considered fatal or incurable; munity. Increasingly, governments are going to want to have a say in what kinds of physicians the medical schools urbanization and mobility; the trend, in the so-called civiland where they practise; here again, it can ized countries to self-induced illness brought on by al¬ produce be reasonably projected that there will be a greater need cohol and drug abuse, smoking, obesity, pollution and in the primary care sector than in some of the more highpromiscuity. powered subspecialties. Inevitably, as those who pay the health bill in Canada So the prognosis for the family doctor in the remaining recognize that we've gone just about as governments 25 years of this century looks very good. far as we can in treating disease, the focus will shift to That family doctor will unquestionably have to have prevention. Federal Health and Welfare Minister Marc .

.

.

1006 CMA JOURNAL/APRIL 19, 1975/VOL. 112

Diseases of choice: the

family

doctor is the

what the executive director of the College of Family Phy¬ sicians of Canada calls the three As Ability, Availability and Affability but he's much more likely to have to document at least the first of these in a systematic way. In the future, evidence of successfully completed continu¬ ing education courses may be necessary, not just as a requirement for college membership, but as a requisite for periodic relicensing to practise medicine. The future family physician's training will likely have equipped him to deal with socioeconomic factors affecting health and to be a manager of the family's health and of the individual's path through the ever more complex health .

care maze.

Continuing to practise medicine not just as a science as an art, the GP will, one hopes, be freed from his practice to update his education (and be given incentives to do so), encouraged to engage in original research and perhaps even given opportunities to spend at least a part but

of his The

career

in have-not societies

or

nations.

big change

But it is in the area of preventive medicine that the future family doctor is likely to see the biggest change from existing patterns of practice. As Brian Inglis writes in his "History of Medicine" (I quoted his comment earlier in this series), "only by a return who knew his patients and their to the family doctor. circumstances (and not just their symptoms) could the ap¬ propriate preventive measures be taken." Of course, a great deal of lip service is paid today to the concept of preventive medicine; yet there appears to be limited agreement about what it consists of. Many family doctors are frustrated in their attempts to "educate" pa¬ tients; most simply don't have the time for such luxuries anyway. But preventive medicine may become more a reality than an ideal in a future in which the GP can work with effective public education programs, with access to com¬ puterized information, within a more streamlined health who knows with a wealth care system and perhaps of new techniques at his disposal to make health main¬ tenance a major part of his practice. One Toronto GP for whom the future has already arrived is Dr. Bob James. For a year he has been using ..

key

to the

preventive effort

biofeedback a technique using electronic sensing equip¬ ment which supplies physiological change information about, for example, skin temperature, heart rate, muscle tensions and brain wave rhythms, so that the patient is fed back an awareness which leads to a psychophysical

learning

process.

James first learned about biofeedback from an article in that most lucid of technical publications, Scientific Amer¬ ican. He has now used it on about 150 of his patients for such problems as anxiety, depression, agitation and for a variety of psychosomatic complaints which, he says, form the bulk of a general practitioner's work. One of the increasing number of patients who are re¬ ferred to James came to him with a severe perspiration problem. Now, after learning to control the sweating using biofeedback, he can talk to his boss more coolly. Essentially, says Dr. James, biofeedback represents one way of linking mind and body, a process formerly asso¬ ciated with Eastern philosophies but now also becoming a part of Western medical technology. James believes that biofeedback will eventually become a routine aspect of general practice and that GPs will regard the electronic sensing equipment involved as being just as useful and as well used as the stethoscope or the thermometer. For one thing, he says, biofeedback very quickly puts the physician in touch with the patient's problem; "more important, it puts the patient in touch with his own prob¬ lem". .

Put

patient

on

team

mean goodbye to the tranquillizers? To some already has in Dr. James' practice. "Giving a patient a pill," he says, "makes him doctor- and chemicaldependent. Biofeedback puts the patient on the health team." The future general practitioner, James believes, will rely less on chemotherapy. He will be more involved with what makes people tick so that he can help them cope. Dr. James is vice chairman of a recently formed Ontario Medical Association section on psychotronics. The recently formed (1974) coordinating committee of the Canadian Academy of Psychotronics is the first such

Does this

extent, it

continued

on

page 1022

CMA JOURNAL/APRIL 19, 1975/VOL. 112 1009

FAMILY DOCTOR continued from page 1009 organization in the world. Started by a young general prac¬ titioner, Dr. Terry Burrows, and electrical engineer Henry Evering, the organization operates out of offices on Toronto's Eglinton Avenue. Burrows, after a few years of general medical practice, began to ask himself about the many diseases he saw in his patients that seemed to have no physical cause but were "all in the mind" the so-called psychosomatic

diseases. The techniques that

psychotronics uses to explore the mind-body-environment relationship include biofeedback, and Kirlian photography, a method of capturing on film changes in the body's electrical energy field. Not that psychotronics is concerned exclusively with medicine: what it's about mainly, says Burrows, is com¬ munication; what it decidedly is not about, he emphasizes, is hypnosis in any form, mind manipulation or control, commercial exploitation of psychic phenomena or cultism of any kind. Soviet researcher Dr. Vladimir Inyushin says that Kirlian photographs have already shed some light on acupuncture. He says that he has seen tiny energy flares at the acupunc¬

ture

points.

At present, Kirlian photography is just one part of the jigsaw puzzle of mind and matter that may turn out to embrace such fields as astrology, telepathy and ESP all of which may be linked by electromagnetism or some other form of energy. Writing about the future of general practice in the New .

GP will work with the total

picture of patient's needs...

England Journal of Medicine (June 11, 1964), another futuristic James, Dr. George James, then commissioner of health for New York City, said that "the family doctor is the key to the kind of medicine and the kind of medical care that is going to be needed in the future." This is especially true, James felt, in the treatment of increasing numbers of older people who will not necessarily be "sick in the hospital-bed sense of acute disease but in the sense they will have continuing medical problems that will need continuing attention. For many of these people, pending further research findings, one is going to have to think not in terms of biological cure but of enabling them to be active and productive while living with their

handicap." Dr. James also had something to say about prevention; he figured that if, say, 1 of 15 patients with cancer of the lung could be saved by surgical intervention, that re¬ presents some progress over the situation prevailing 20 or 30 years ago. But, he points out, one could probably pre¬ vent 12 of those 15 cases by eliminating their cigarette smoking early enough. "The family doctor's efforts in this field, if successful in erasing the smoking habit, would make him 12 times more effective in saving lives than the best of surgical specialists." The excitement of tomorrow's medicine, James points out, will be in rehabilitation more than in complex surgery, in prevention more than cure. Within that framework the GP will work with the total picture of his patient's needs, abilities and strengths "all in terms of the patient's environment and mode of life." Since an important part of future medicine, Dr. James contends, will consist of convincing people to adopt habits conducive to good health, the family physician, who knows his patient, will be ideally placed to provide this service. "The specialist, whose interest is in some part of the pa¬ tient's anatomy and who floats in and out of the patient's life with intensive rapidity, is not the man for this job." Whatever the future holds for general practice, its prac¬ titioners are likely to mold themselves to it successfully. As Victor Johnston says in his "Before the Age of Mir¬ acles", "Adaptation is the juice of family medicine the GP adapts to the needs of people or closes up shop."H .

The family doctor in Canada. Part VIII. The way ahead.

The family doctor in Canada. Part VIII: the way ahead By David Woods Lalonde has devoted a book, "A New Perspective on the We have seen, in this serie...
1MB Sizes 0 Downloads 0 Views