The specialty of family medicine in Canada

“[W]e take specialty to be not one of special focus, but of special expertise, special competence.”

—Meittinen and Flegel¹

More than 35 years ago, the federal government granted the College of Family Physicians of Canada (CFPC) the authority to grant Certification in the CFPC (CCFP) as a special designation for family physicians who demonstrated special competence in the discipline of family medicine. More than 14 000 family physicians now hold this Certification.

Requirements for CCFP designation include successfully completing formal residency training (or a practice-eligible alternative) and passing examinations similar to those for certification and specialty designation in the disciplines of the Royal College of Physicians and Surgeons of Canada and many sister family medicine and other specialty Colleges around the world. In the United States, Australia, and many European Union and South Asian countries, family medicine is a specialty; those holding the equivalents of our CCFP are recognized as belonging to that specialty.

In April 2005, the CFPC’s Board of Directors established a Steering Committee to explore more formally recognizing family medicine as a specialty in Canada. A key challenge is to allow experienced non-certified family physicians to achieve Certification and become part of the specialty. The Steering Committee welcomes your feedback (info@cfpc.ca) as it continues its deliberations.

For years many family medicine Certificants have asked why our discipline has not been recognized as a specialty in Canada. The same question is now also being asked by many others, who see potential benefits in being able to identify and give credit to family physicians who are part of a specialty that requires demonstration of competencies initially and then requires a commitment to lifelong learning: medical schools considering appointments and promotions, regulatory bodies developing peer assessment programs, research bodies reviewing grant applications, hospitals focused on credentials and privileges, medical associations and governments seeking to eliminate the unacceptable gaps in remuneration levels between family physicians and other specialists, and patients verifying the credentials of the physicians caring for them.

Importantly, medical students are also asking why (especially when we need to attract more graduates to family practice) family medicine is not being presented to them as a specialty that is as important and prestigious as the other major disciplines. Family medicine’s established body of knowledge; commitment to evidence-based practice; strong academic and research base; progressive postgraduate training programs; and internationally acclaimed examinations, Certification, Maintenance of Certification, and Fellowship programs—all defining elements of recognized specialties—make their question hard to answer.

Many believe that family medicine became a specialty long ago. In 1979, in Strength in Study: an informal history of the College of Family Physicians of Canada,² David Woods wrote, “With family medicine in Canada today recognized as an established specialty, it is difficult to keep track of the many battles that had to be fought along the way to acquiring that status.” In the Globe and Mail’s tribute to his life published on May 21, 2005, the late Dr Donald I. Rice (CFPC Executive Director from 1965 to 1985) was described as believing that the “introduction in the 1960s and 1970s of medical school–based residency training and the Certification process defined family medicine as a specialty in Canada.” Responses from sister organizations who were asked whether they believed family medicine should be recognized as a specialty in Canada included “You mean, it isn’t one already?” and “Yes—it’s about time!”

Discussions of specialty status for family medicine have sometimes focused on whether becoming a “specialty” diminishes family doctors’ important role as “generalists.” Canadians clearly tell public pollsters how highly they value family doctors and health care providers who have a generalist and holistic approach. Yet, like all Western populations, they also express a preference for specialization when seeking professional advice. Internationally, where family medicine is a specialty, most agree that generalism and specialization are not opposite extremes of a continuum and that they can and do coexist quite naturally.¹

Whether or not family physicians are called specialists could be a matter of personal preference. As the Europeans have stated in recognizing family physicians as the specialists most expert in providing a generalist approach, “semantics and politics should not impede the progress of general practice.”³ The critical issue is less about each physician and more about the domain in which these physicians practise—about whether or not the discipline of family medicine should be acknowledged as the specialty it truly is.

When recognizing a new specialty, many certifying bodies (including the Royal College) have recognized experienced but non-certified physicians who had been practising in the field for years by offering them a time-limited alternative pathway to Certification without examinations. A Working Group of our Steering Committee, comprising both Certificants and non-Certificants, is currently developing recommendations for a similar pathway in family medicine. Many non-certified family physicians in rural and urban communities across Canada have been asking us for years to consider offering an opportunity like this. They have often shared with us their passion for family medicine; their understanding of the principles; and their commitment to the same body of skills, knowledge, and attitudes as their Certificant colleagues. While each physician will be free to choose whether to participate or not, we hope that many will see this as a positive and progressive step.

Introducing an opportunity for experienced family doctors to achieve Certification and acknowledging family medicine as a specialty could foster many positive changes for family practice across Canada, including enhanced credibility for the discipline and greater respect for its physicians. Historically, physicians in many other medical fields have had greater opportunities for appointments, promotions, and research awards along with increased remuneration after their disciplines were recognized as specialties. Changes like these could help attract more graduates to careers in family medicine and retain experienced family doctors in their practices. A larger and re-energized family doctor work force across the nation would improve access to care for all Canadians and reinforce our vital cadre of family medicine teachers and researchers. Being part of a recognized and strengthened discipline would help restore family physicians’ pride in being the prime caregivers so highly valued by their patients.