“You can’t eat scenery”

In a famous scene in the classic film Modern Times, Charlie Chaplin’s beleaguered factory worker character frantically tightens bolts on a speeding conveyor belt before being swallowed up and carried into the subterranean cogs and wheels undergirding the factory.¹

For me, many days in the family medicine clinic now feel like that, too. This summer, the hospital where I work sent a time-and-motion observer to follow several of my family medicine colleagues around. Surprisingly, the observer discovered that 70% of my colleagues’ work hours were spent in front of a computer screen. Face-to-face time with patients made up only one-third of the workday.

In his 2008 book, British general practitioner and researcher Dr Steve Iliffe carefully documented the many forces leading to the industrialization of family medicine: an aging population living with multiple chronic health problems, the rise of evidence-based medicine, the proliferation of clinical practice guidelines, the influence of consumerism, and the beginning of interdisciplinary team-based care in general practices.² Back then, these forces were already making family medicine more complex.³

Since 2008 we have seen the widespread adoption of electronic medical records into family practice and across health care systems, adding another element of complexity and contributing to burnout.⁴ Since 2020 we have also borne the brunt of a global pandemic, the impact of which will reverberate for years to come.⁵

It is impossible in a journal editorial to do justice to the many issues that Dr Iliffe grappled with in his book. He also argued that many of the transformations taking place in family medicine are necessary to prevent the profession from reflexively resisting change and to help FPs and their leaders contribute meaningfully to transformation aligned with our values.

In the 2023 Dr Ian McWhinney Lecture published in this issue of Canadian Family Physician (page 821 ), Dr Iona Heath revisits the values of family medicine that the late Dr Ian McWhinney articulated in his writings, enlarging on and amplifying them for the difficult times we live in now. It is these values that give both meaning and beauty to our difficult work.⁶

Dr Heath begins her lecture by describing that “jolt of recognition” many family doctors experience when they first encounter Dr McWhinney’s “quality of mind.” For her, it was caused by this passage in A Textbook of Family Medicine:

Human variability is such that for a seriously ill person, the physician cannot be a replaceable part. If we insist on treating ourselves as such, we should not be surprised if society treats us as laborers rather than as professionals. We should also not be surprised if it does something to us as people. As we withdraw from our patients, we will be the poorer for it.⁷

This withdrawal is the core danger that both family doctors and their patients must resist as family medicine continues to industrialize.

As I reflected on this year’s lecture, a beautiful scene in the 1983 movie Local Hero came to mind.⁸ The protagonist, Mac, a Texas oil company executive, is sent to a remote Scottish village by the sea to buy it and the surrounding land, which are sitting on oil deposits. As he gets to know the people and the landscape, he comes to regret his original mission. After the villagers agree to sell their land, he commiserates with Victor, a Russian fishing boat captain who visits the village from time to time, drawn to the beauty and to the people. As Mac laments the imminent industrialization of the village, Victor reminds him: “You can’t eat scenery.” You cannot eat values, either, but it is hard to live and work meaningfully without them.