‘This problem could easily have been dealt with by the family doctor’

“This problem could easily have been dealt with by the family doctor.” This statement I have witnessed a number of times over the course of my time as a family physician, seen in the charting by specialists, or in overhearing a discussion of a clinical problem with one another. While somewhat offended by this, on reflection, I wonder if it isn’t symptomatic of a failure in collegiality in our profession. I am very concerned that we are suffering more and more from a drought in collegiality, which leads invariably to increased practice isolation and, ultimately, reduced quality of care for our patients. Ideally, what should unite us all is the shared experience of our years in “boot camp.” Long hours of study, bedside learning, lectures, residency training and developing the capacity for developing intimate, trusting relationships with people. We share almost overwhelming expectations from our patients. Lifelong learning is critical to our work and we are expected to know the latest guidelines and evidence-based information as part of this. Then, we continue to deal with hostile and aloof bureaucracies who, although tasked with fiscal responsibilities, rationalize to the public their failure to reasonably fund medical services in certain sectors, particularly in family practice and pediatrics, by blaming physicians for making too much money. Meanwhile, we struggle with significant overhead costs which are rise every year. All this we have in common with one another and it should unite us.It remains spotlessly clear to this writer that we need to support ourselves, to care for one another, to reach out to one another through professional societies, both regional and provincial. We must form bonds with our colleagues. We must try and put ourselves in the shoes of out colleagues before we become critical of them. The stigmatizing opening statement illuminates my point. Was the critical specialist expressing an underlying disdain for the primary care physician’s clinical acumen, or was the referring physician indeed just dumping a case (thus justifying the comment)?The reality is, many family doctors can work simply as triage units. Abdominal pains? Off to the gastroenterologist you go! Sorry about the waiting time. Specialist colleagues will speak referral letters such as: “Constipation NYD.? Hirschprung’s Disease?” or, “Abd pain NYD. Plse assess.” Both of these are shallow, dismissive letters, failing to advise the specialist of what findings, if any, were found, what investigations the doctor undertook and what diagnoses were considered. They are indeed insulting to the specialist.A proper letter, stating the referring doctor’s workup and investigations sets the stage for the specialist to appropriately move forward with other more focused investigations, but it also helps them immeasurably. A specialist who receives comprehensive notes, including past and family history, won't just be thankful, but also all the more receptive to referrals in the future. It's very rewarding to receive a note back from a specialist thanking me for a helpful note.On the other hand, a specialist may have a poor understanding of the pressures on family doctors, and, carrying this negative image, be primed to respond critically to referrals. But there may be a shift in general attitudes towards colleagues. A retired obstetrician told me recently that he was treated quite unfairly some months back. In partial retirement at that time, he was performing colposcopies at an outpatient clinic. He was suddenly notified by the Chief of Obstetrics that he would no longer be doing colposcopies as a new specialist had come to town, and would take this over. This lack of proper process and notification hurt him considerably. To add insult to this, the new physician never came to meet him; it is as if he never existed. A sad state of affairs indeed. Are doctors going to gradually operate in a professional vacuum like this in years to come?In Peterborough, Ont., the monthly meetings of the Peterborough County Medical Society fought this vacuum for years. But attendance has dropped to the extent that now, meetings are every three months. I once asked a young radiologist if she might be interested in coming to the meetings, and she told me that she wasn’t interested because it was “an old boys’ club.” I responded that if she and her peers didn’t come, then indeed, that is what it would become. However, I believe that in Peterborough there is now a female physicians’ society. Unless these doctors also attend our Society meetings, such splintered socializing risks becoming a barrier to forming collegial bonds between all physicians in our community.Socializing bolsters collegiality. Someone with whom you shared a cold beverage is going to be available to discuss a clinical problem with you in the middle of a busy afternoon. They know you aren’t calling for a superficial reason. Many times I've rung up a radiologist in the hospital for some direction in ordering imaging, and engaged in a pleasant, unhurried conversation around the differential diagnosis, and appropriate imaging. Collegiality meant a willingness to share time with a colleague in the name of good care and appropriate use of resources. You didn’t just send everybody for an MRI. You ensure proper imaging and save time, money and improve efficiency in the radiology department down the road.Socializing as part building collegiality in a medical community also allows practitioners to learn what special skills and interests other doctors in the community have. One of our emergency physicians provides therapeutic hypnosis part-time. It was nothing to corner him at one of our meetings to ask about his practice, and learn how to refer to him. The benefits for patient care from such interactions have been substantial over the years.A bunch of my classmates from the Meds Class of 1973 from the University of Western Ontario remain in touch via group emails. We agree that collegiality is a cornerstone of the profession of medicine, and that there is evidence of erosion of this vital component of who we are, which is harming the profession.Positive results with collegiality:Increased/sustained professional satisfactionIncreased sense of community within the professionIncreased/sustained sense of self-worthRegular confirmation of one’s work results/work ethicElevated happiness indexExpansion of knowledge boundariesNetworkingCollegiality gives us strength. Without it, we lack unity and conviction.It is point number eight that needs further consideration. For decades, I witnessed a continued devaluation of the work of physicians in Ontario. The sources of this were largely systemic. Politicians were openly hostile or dismissive. Bureaucrats viewed us as the enemy. But sadly, greed within the profession played a part. For decades, the Ontario Medical Association failed to adequately support the remuneration distribution to family doctors. Presently, core fees paid by OHIP are about 60% of what they should be in today's dollars. I believe at the level of the OMA, some specialist groups, fuelled by a sense of entitlement and privilege, lobbied and influenced the dispersal of monies. It is widely known that family physicians, pediatricians and psychiatrists experienced restricted growth in their fees over a number of decades because of failure by the OMA to address their needs.I believe that the lack of collegiality among physicians was a large cause for this behaviour. In major centres in Ontario, specialties very seldom cross paths with family doctors. They are remote to each other. Opportunities to come together as members of a profession that theoretically should have much in common with each other, don’t happen. But they must.If medical practitioners live and work in isolation from one another, we will be completely open to manipulation by governments and bureaucrats. Dr. Tom Bell is a past medical advisor to the Schizophrenia Society of Canada an and a retired adjunct professor of Family Medicine in the Queens University. Dept. of Family Medicine. He is a current board member of the Morton Medical Centre in Lakefield.

‘This problem could easily have been dealt with by the family doctor’

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