In all, 27 individual and 14 group interviews were conducted with 92 respondents, providing a comprehensive sample. All associate deans and all program directors, with the exception of two in radiology, participated. Table presents our respondents' characteristics. Because no salient mission-based differences were observed between schools, this parameter was discarded during analysis. Results are organized in two sections: generalist-specialist collaboration in the formal curriculum; and collaboration as experienced in practice in academic medical settings.
Generalist-specialist collaboration in the formal curriculum: non specific and scattered competency objectives
Content analysis of official documents revealed collaboration competency objectives in all programs. These were institutional, diverse, and mentioned under different competencies.
In describing collaboration skills, specialty programs generally referred to the "interprofessional team" or "other health professionals", without specifically mentioning family physicians. All specialty programs identified referral and consultation skills under the "Medical expert" competency; three referred to specialists' responsibilities in the continuing education of generalists under the "Scholar" competency; two internal medicine and three psychiatry programs mentioned the importance of communicating information about patients to their family physician upon discharge from the hospital under the "Communicator" or "Collaborator" competencies; and four programs had indications such as "Demonstrate the attributes of a good consultant" under the "Professional" competency. All family medicine programs mentioned "learning to make appropriate and timely referrals" under the "Skilled clinician" principle; no other indication concerning relationships with specialists was found.
This lack of detail and uniformity across programs was echoed in our interviews. All residents considered consultation skills a competency to be mastered, but generally indicated that learning intra-professional collaboration was not formalized in clinical rotations, except for psychiatry programs. Collaboration was learned "on the job", and location appeared to play a critical role. Indeed, indications were found that rural settings might favour better generalist-specialist collaboration, compared to university hospitals, where it was not considered a priority.
"I am in a region. Here, as family physicians, we have very close contacts with the basic specialties.... It's a good experience because they [residents] don't often have the opportunity to see this kind of teamwork between family physicians and specialists, with a case management role for the family physician and a consulting role for the specialist." (Family physician educator)
"Not so much here [university hospital], but in other places some of the internal medicine services [wards] had a policy whenever they discharged a patient, they would make a courtesy call to their doctor so that they would know that the patient had been in the hospital... but again, that didn't happen every day...." (Internal medicine resident)
Collaboration as experienced in practice in academic medical settings
Even if collaboration between family physicians and specialists is not always formally addressed in the curriculum, the academic training settings provide many occasions to experience it. From the interviews, it is clear that the referral/consultation process sets the stage for collaboration. Generally speaking, respondents expressed similar ideas on what constitutes effective collaboration: clinical relevance of the referral, good communication skills, and clear definition of responsibilities. However, in practice, collaboration runs up against certain obstacles and does not always meet expectations. Many issues were raised such as lack of clarity about the reason for referral or about the results of the consultation and confusion about each others' roles. Lack of time, fee schedule that does not permit reimbursement for telephone consultations and inadequate information systems were also identified as major irritants in day-to-day practice, mainly by the educators. Yet, many comments revealed more deeply-rooted problems. Those problems were classified under two major themes related to Abbott's conceptual framework: issues of professional responsibility and recognition of mutual expertise; and expanding distances between family practice and specialty care in the workplace and in the training programs.
Issues of professional responsibility and questioned expertise
Frequently experienced problems were related to inappropriate acknowledgment and coordination of roles. For example, specialists were uneasy leaving it to family physicians to follow their advice:
"Family doctors must realize that, when we do write back to give them advice, we expect that the advice will be heeded. We do appreciate it when we send our advice in the form of consult letters to family doctors and the advice is recorded and recognized." (Internal medicine program director)
For vulnerable clienteles, they worried family physicians might not be sufficiently available or have the resources for follow-up:
"I have seen patients that I'd seen in consultations: it didn't work out to send them back to the family doctor. They came back to the hospital because they've been getting gradually sick over a period of two, six, eight weeks, without anybody being able to identify... they were not able to get through to their family physicians." (Internal medicine educator)
Family physicians, conversely, were annoyed when specialists "took over" their patients–particularly when they referred them to other specialists–because responsibilities were often unclear:
"I have to refer to specialists who don't know me and who act as if they have control over the patient entirely without any input from me. Specialists being very unclear in their letters.... 'This patient should have X, Y, and Z.' Does that mean you've ordered it? Does that mean I'm supposed to order it? Are you going to follow this patient? Not clear...." (Family medicine educator)
It was the specialty residents who had more perspective on the challenges of learning to work as consultants in collaboration with family physicians.
"In my two years as a senior resident, what I learned was how to be a good consultant. It isn't easy. Particularly in internal medicine, where we want to do it all, control everything, while the consulting role is about learning to be clear in our oral and verbal communication, to let people make their own decisions while offering alternatives." (Internal medicine resident)
"The other issue with general internal medicine is oftentimes they [family physicians] refer a specific problem to us, so we investigate it further. And in the process of doing the history and physical there's another issue that needs to be dealt with, or some unexplained weight loss... And I find that a little surprising sometimes, to be honest, that a really obvious physical finding might have gone undetected, or the potential implications of it were not identified. And the other thing that I'm a little bit concerned about is whether or not there are slightly different standards as well, depending on where you are." (Internal medicine resident)
When questioned about his supervisor's advice regarding such a situation, this resident responded that most often the decision was taken to pursue the investigation without notifying the referring physician.
Overall, we noted that the educators were generally less reflective than the residents about the challenges of the consultation process and expressed more stereotyped negatively tainted experiences of intra-professional collaboration.
Expanding distances between specialty and family medicine in the workplace and in the training programs
Queried on the reasons for these collaboration issues, our respondents noted expanding distances between family physicians and specialists regarding the workplace and training settings, two key fields of professional identity enactment and development according to Abbott's theoretical framework.
Many family medicine and specialty educators noted the distance introduced by family physicians' gradual shift from hospitals to private offices and community settings and its impact on collaboration:
"And that's what's been lost by the family doctors leaving the hospital environment.... they used to see their patients in the hospital, used to assist on their own surgeries and everything, they developed relationships with specialists." (Family medicine educator)
Collaboration was also said to be neglected as both generalists and specialists are isolated in their respective work settings, due in part to organizational limitations regarding the transfer of information:
"We don't have a good system for communicating what's going on in the hospital to the family doctors. And a good hunk of that is our fault, I don't doubt it, because it's a time-consuming process to track down the family doctor; they're not in the office when you call them, they call you back and you can't remember the specifics. It's a very tedious process and not very many of them come into the hospital anymore to see patients." (Internal medicine educator)
"There seems to be little commitment on the part of many of the specialists to facilitating the care provided at the primary care level". (Family medicine educator)
Our respondents' discourses also revealed that this distance in the workplace arena–attributable to the evolution of the health care system–was accentuated by another important one resulting from the evolution of the medical training curricula. Indeed, program directors and specialty educators attributed the relative lack of generalist-specialist interactions to the fact that family medicine programs generally moved their residents out of specialized rotations in teaching hospitals and into community-based training:
"They [generalists] ... suggest that their training program should be done in the communities so they disenfranchise their trainees at the beginning and make them different from anybody else ... and therefore they lose the skills that all the other groups have within the hospital scene. ... They learn not to work with the other acute-care or the other specialties and so they're distancing themselves even more." (Internal medicine educator)
Consequently, many specialists we interviewed said they were unfamiliar with family physicians' current training. This situation led some of them to believe it was done "at a discount", a situation we found to be associated with the issues of professional responsibility and the questioning of expertise mentioned earlier:
"I wouldn't have a clue as to where [family physicians] are getting trained. There hasn't been a single family practitioner to come through our training program in years.... that's a real problem because I think family physicians do an extraordinary amount of mental healthcare.... I don't know if they're trained for it." (Psychiatry program director)
In the view of some educators and many associate deans of postgraduate studies, this second distance is rooted in part in the fact that there are two systems for defining the functions of a physician depending on whether you are talking about a family physician or a specialist. This complicates the integration of residents in formal teaching activities:
"Oh, CanMEDS has seven roles, but Family Medicine has four principles... I know that there is a 'turf' issue here, but I wish the two colleges would get together and call their roles the same thing. You know, the four principles have all of the CanMEDS roles in them. If you just break them down, you can find them. It would be helpful if all our students would have all the same names for their roles. We now have actually adopted the CanMEDS roles as primary initiatives in the undergrad curriculum. It would make family medicine equal to all the other specialties, as opposed to being off by itself." (Associate dean of postgraduate studies)
"What would I do differently? I would take away the two-class system of training and make all trainees go through much the same training." (Internal medicine educator)
Finally, two specialist respondents alluded to a perceived lack of contribution of family physician educators to the production of scientific medical knowledge–which is another important aspect of the professional system in Abbott's theory–as contributing to the observed problems of collaboration:
"It has been an issue in the training program ... specialists have not viewed family physicians as being at the same level ... because they're not doing the same kind of other academic work that the specialists are doing. I think as soon as we see a family physician who is just as involved in scholarly activity, I think the equal, mutual respect would be the same as two specialists talking to each other." (Associate dean of postgraduate studies)