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We cannot market the unsaleable


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Vol 53:  july • juillet 2007 Canadian Family PhysicianLe Médecin de famille canadien


Correspondance  Letters



r  Steben  is  correct  in  that  the  photograph  of  the  patient  with  pathologic  phimosis  has  concurrent  balanitis  xerotica  obliterans  (BXO)  or  lichen  sclerosis  et  atrophicus.  In  the  pediatric  age  group  there  is  an  association between the two. This does not represent  a “diagnostic error,” however. Although the BXO might  respond  to  high-potency  topical  steroids,  it  has  been  our  experience,  and  that  of  others,  that  the  scarred  phimotic  ring  rarely  does.1  Balanitis  xerotica  obliter- ans  might  require  treatment  with  topical  steroids  for  a time after circumcision, but in most cases removing  the  pathologic  foreskin  will  resolve  the  problem.  The  risk of cancer of the penis with BXO is not pertinent to  the  pediatric  age  group,  as  the  condition  is  reversed  by timely circumcision with or without topical steroid  application.  The  biggest  risk  in  children  is  the  devel- opment  of  meatal  stenosis  secondary  to  BXO,  which  might require meatotomy.  

—Michael P. Leonard MD FRCSC FAAP

Ottawa, Ont by e-mail Reference

1. Webster TM, Leonard MP. Topical steroid therapy for phimosis. Can J Urol  2002;9(2):1492-5.

We cannot market the unsaleable


he Commentary article by Ivers and Abdel-Galil1 about  improving  marketing  of  family  medicine  is  a  praise- worthy attempt to put a brave face on family medicine’s  poor reputation. Their solution, to “make a good offence,  and change the perception of family medicine” is good as  far as it goes, but it is a salesman’s approach. Sadly, even  the  best  marketer  finds  it  difficult  to  sell  a  second-rate  product: like North American cars, when Japanese brands  are available.

Even  worse,  the  idea  of  selling  niche-market  fam- ily  medicine  to  those  who  find  the  main  approach  unattractive is avoiding the real issue. Medical students 

and  their  in-hospital  preceptors  are  not  fools.  They  can  see  the  reality.  Yes  indeed,  family  medicine  does  include many who came into it because we love what  we  do  and  try  our  hardest  to  do  it  well.  But  it  also  includes many who trained in our specialty because the  system would not let them do what they really wanted. 

Some  of  these  accept  the  station  in  life  to  which  the  Canadian  Resident  Matching  Service  has  called  them,  others  move  into  niche  practice  close  to  what  they  wanted,  while  others  become  “bottom-dwellers,”  aim- ing  to  get  away  with  the  minimum  work  at  maximum  speed  for  maximum  pay.  Their  patients  are  overrep- resented  among  the  patients  seen  by  specialists,  with  inappropriate  referrals,  poor  diagnoses,  and  unavail- able  follow-up,  so  biasing  the  perception  of  family  medicine overall. 

Sadly,  when  the  pay  and  conditions  for  community- based, continuing, comprehensive family medicine are  so much less desirable than those for many of the spe- cialties,  it  is  unreasonable  to  expect  bright  young  peo- ple  with  debts  and  family  commitments  to  join  our  ranks. Some of those who entered with high ideals feel  let down when the reality sinks in.2 Most of the discus- sion about earnings is misleading; even if family physi- cians earn 80% of specialists’ gross income, their office  overheads and the cost of paying back debt and feeding  a  family  are  similar,  leaving  specialists  with  a  dispos- able  income  several  times  higher.  If  a  gastroenterolo- gist  has  an  entry  salary  of  $252 000,  that  is  more  than  a  full  professor  of  family  medicine  can  currently  hope  to  earn.  Someone  must  have  decided  that  this  dispar- ity  has  some  relationship  to  our  value  to  society.  How  can  I  as  a  professor  honestly  tell  undecided  students  that  they  should  join  our  program  and  thereby  earn  much less than if they spent an extra year or two train- ing in most other fields? And if they graduate in family  medicine, they find that niche practice pays better and  provides a better lifestyle. Yes, the personal rewards of  family  medicine  work  are  wonderful,  but  I  have  heard 



Canadian Family PhysicianLe Médecin de famille canadien Vol 53:  july • juillet 2007

rumours  that  other  specialties  find  satisfaction in their work—and their  bank balance too!

Until  the  economic  bias  against  family medicine and rural medicine  (and  other  thinking,  nonprocedural  specialties)  is  reduced,  it  would  be  morally  wrong  to  spend  effort  mar- keting  to  students,  earning  us  a  reputation for mendacity as well as  incompetence.  Instead,  the  College  should  spend  effort  selling  the  ben- efits of mainstream family medicine  to  the  people  who  decide  the  fund- ing  allocation  within  the  Canadian  health  care  system.  It  is  pleasing  that  in  the  same  issue  of Canadian Family Physician,  Dr  Gutkin,  the  Executive  Director,  makes  this  point.3 Doing this might lead to stu- dents wanting to join us, especially  if we increase the training and raise  expectations  of  our  graduates,  so  family medicine really does provide  consistently high quality. 

—James A. Dickinson MB BS CCFP PhD FRACGP

Calgary, Alta by e-mail References

1. Ivers NM, Abdel-Galil R. Marketing family medi- cine. Challenging misconceptions. Can Fam Physician 2007;53:793-4 (Eng), 796-7 (Fr).

2. Suende T. Money talks—and this resident is start- ing to listen. National Rev Med 2007 May 15, p. 39.

3. Gutkin C. The voice of family medicine. Can Fam Physician 2007;53(5):963 (Fr), 964 (Eng).



e believe Dr Dickinson makes  his  point  well  about  the  finan- cial disincentive to choosing family  medicine  and  agree  with  his  asser- tion  that  the  best  way  to  improve  remuneration  is  to  convey  the  mer- its  of  family  medicine  to  the  pol- icy makers in charge of funding and  pay structures.

We  do  take  issue  with  the  notion  that  using  marketing  tech- niques  to  find  out  which  elements  of  the  job  are  most  appealing  to  medical  students  and  advertis- ing  techniques  to  better  commu- nicate  those  strengths  is  “morally  wrong.”  We  believe  that  it  will  be  most efficient for the profession of 

family medicine to spend time and  money  to  better  understand  what  medical  students  know  and  don’t  know  about  family  medicine  in  order  to  better  target  the  best  and  brightest for recruitment.

If,  as  Dr  Dickinson  suggests,  medical  students  are  frequently  exposed to the less than ideal care  provided  by  those  family  doctors  who would rather not be in our spe- cialty,  then  it  becomes  even  more  important  that  we  make  an  effort  to  prove  that  good  family  medi- cine  is  possible.  In  this  regard,  we  strongly  affirm  the  potential  value  of  positive  role  models  and  men- tors, in addition to market research  and advertising techniques.

In  our  opinion,  there  is  no  reason  to  allow  recruitment  to  languish  while  waiting  for  gov- ernment  reforms  to  occur.  Rather,  a  young,  motivated,  and  invigo- rated  influx  of  bright,  young  doc- tors  who  understood  the  benefits  of  family  medicine  and  chose  it  willingly  and  fully  informed  could  only  strengthen  the  force  of  advo- cacy  for  the  reforms  Dr  Dickinson  desires. To be clear: we simply feel  that, for a variety of reasons, many  medical  students  discount  family  medicine  as  a  career  choice  too  early  and  never  find  out  if  it  could  be  right  for  them.  We  share  many  of  Dr  Dickinson’s  concerns,  yet  stand  by  our  recommendation  that  the  College  investigate  the  value  of  a  marketing  campaign  to  bet- ter  communicate  the  merits  of  the  specialty  and,  through  improved  recruitment,  strengthen  the  profes- sion itself.

—Noah Michael Ivers MD

—Ramzy Abdel-Galil MPA MD Toronto, Ont by e-mail

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