The Emperor's Clothes

Abstract

A RECENT Ontario survey ' reported a continuing decline in the numbers of family physicians who provide intra-partum maternity care. Physicians who at one time practised obstetrics most often cited interference with personal and family life as the reason for discontinuing this component of their practice, although concerns about competence and the number of annual deliveries needed to maintain skills were also frequently mentioned. Physicians who had never provided maternity care gave inadequate training as the main reason for their decision not to become involved. It seems ironic that such dramatic changes are taking place at the same time that evidence2-4 is accumulating that the obstetric care provided to lowrisk patients by generalists is at least as safe as, if not safer than, the equivalent care provided by specialists. In this month's issue Drs. Reynolds (page 1937) and Hogg (page 1943) discuss the significance of these changing patterns of practice and their implications for patient care. Their arguments that family physicians do indeed have a contribution to make to maternity care are, I think, bolstered by the other papers in this issue written by family doctors that demonstrate a wide range of experience and knowledge in this area of medicine. What accounts for the discrepancy between the views ofmany family physicians about their obstetric abilities and the evidence that suggests that they provide care that is, by any measure, adequate? What factors might undermine the confidence physicians must have in their knowledge and skills to continue delivering maternity care? Robert Chase,5 writing in the New England Journal of Medicine, provides what I think might be a partial answer to this question. He argues that medical specialties, such as obstetrics, go through a characteristic life cycle ofdevelopment. In the first place, as a result of interest in a particular field, a group with apparently special skills comes together, and forms an organization to provide mutual support and a forum for the exchange of ideas. Membership in the organization then becomes a mark of distinction in the field, and in order to substantiate that recognition, certification of excellence becomes established. Institutions with responsibility for the quality of health care then accept certification as evidence of competence and move to limit the provision of care in the field to those who are so certified. A consequence of this series of events, Chase comments, is that as a specialty develops and gains recognition, certification becomes a permit to practise. Non-specialists then begin to have doubts about their competence to deal with anything in that special area, doubts that are reinforced by the actions of health-care institutions in attempting to limit practice. Non-specialists begin to refer both complex and simple problems to a certified specialist, and this step, in turn, tends to diminish the non-specialists' own competence by reducing their exposure and experience until, eventually, they refer all such patients to the specialist. The specialist, on the other hand, may initially welcome these patients, but soon begins to resent referral of non-complex patients and starts to think of the non-specialist as incompetent by virtue of his need to refer such simple straightforward problems. "Soon," Chase concludes, "the specialist is inappropriately occupied with problems that do not require his special talent, and the non-specialist is gaining more and more a sense of incompetence. It has been that fear of perceived incompetence of general primary-care physicians that has kept many students from choosing such a non-system, nondisease and non-technique focussed practice. The cycle itself tends to perpetuate and increase the imbalance between primary-care physicians and specialists. " The cycle that Chase describes holds true not only for obstetrics but also for all those other areas of practice in which special-interest groups have captured a piece of the medical pie and acted to exclude, or at least severely control the access of, others on the ground of their own greater expertise. Indeed, the development of modern medicine itself is a good example of the process in action as the control ofhealth care moved from the "generalist" family unit and local folk healers to the "specialist" physician. Back in 1421, for example, the universities in England petitioned Parliament to establish some control over the practise of physic because "many uncunning and unapproved on the foresaid science (of physic) practise." It was not until 1512 that an Act concerning physicians and surgeons was passed. It decreed that no one, unless he was a graduate of Oxford or Cambridge, could practise physic, unless he was licensed by the Bishop of his diocese. Six years later a group of physicians moved to establish their control over the discipline when, in 1518, Henry VIII incorporated the Royal College of Physicians of London to oversee the practice of medicine within a sevenmile radius of the City of London. The proposed function of the College was to "curb the audacity ofthose wicked men who shall profess medicine more for the sake of their avarice than from the assurance of any good conscience, whereby very many inconveniences may ensue to the rude and credulous populace. " There is little evidence that the College members had any intention of offering their services to the "rude and credulous populace"; they acted, rather, to ensure their own control and monopoly of medicine, defining themselves6 as "the first class of medical