E550 CMAJ | APRIL 30, 2018 | VOLUME 190 | ISSUE 17 © 2018 Joule Inc. or its licensors R esidency positions for family phys­icians went unfilled, family doc­tors were in short supply, and patients or whole communities went with­ out primary care. That was in 2003. There was even a hit Canadian film that year, La grande séduction, about a Quebec village trying to recruit a family doctor. “We experienced a nadir in the num­ ber of graduating medical students who chose family medicine, at 23% to 24%,” said Dr. Francine Lemire, executive direc­ tor and CEO of the College of Family Phys­ icians of Canada (CFPC). Fast forward 15 years and the situation is similar in the United Kingdom, said Dr. Katie Coleman, clinical lead for pri­ mary care across north London. She described a “significant shortage” of gen­ eral practitioners (GPs) in the National Health Service, with numbers declining and rural areas going underserved. Canada has bolstered students’ career choice of family medicine, partly by rec­ ognizing family medicine as a specialty in its own right in 2007. Coleman and many others think such recognition would help in the UK as well. The CFPC had the authority to declare family medicine a specialty, but such recognition in the UK must overcome a legislative hurdle. “The Medical Act 1983 has to be changed,” said Coleman. “We would have done this sev­ eral years ago if it wasn’t for that.” Coleman started a petition to have general practice so recognized, but she said she will not get the 10 000 signatures needed in a six­month period to trigger a mandatory response from the govern­ ment. However, efforts by other advo­ cates, including the Royal College of Gen­ eral Practitioners, will continue. Does calling family medicine a spe­ cialty really make a difference in recruit­ ment of family docs? “I would like to believe that it does,” said Dr. Heather Osborn, a specialist in head­and­neck surgical oncology at Yale University, who conducted a study of factors in residency choice at Western University in London, Ontario. T h e s t u d y f o u n d “ t h r e e d i f f e r e n t broad areas that predisposed students to choose primary care,” said Osborn. Those areas are work–life balance, duration of program (two years instead of five), and the physician–patient relationship (hav­ ing a long­term relationship with patients and providing comprehensive care). But students were drawn to other specialties by factors that included “becoming an e x p e r t , ” “ p o t e n t i a l l y e a r n i n g a h i g h income,” and “perceived status among colleagues.” Osborn thinks seeing family physicians as high­status experts will require a cul­ tural shift. “That idea of the family practi­ tioner as a gatekeeper who passes on problems to specialists is not the reality any more. Family physicians have a NEWS Recognition of family physicians as experts rather than gatekeepers requires “cultural.

1. E550 CMAJ | APRIL 30, 2018 | VOLUME 190 | ISSUE 17
© 2018 Joule Inc. or its licensors
R esidency positions for family phys-icians went unfilled,
family doc-tors were in short supply, and
patients or whole communities went with-
out primary care. That was in 2003. There
was even a hit Canadian film that year, La
grande séduction, about a Quebec village
trying to recruit a family doctor.
“We experienced a nadir in the num­
ber of graduating medical students who
chose family medicine, at 23% to 24%,”
said Dr. Francine Lemire, executive direc-
tor and CEO of the College of Family Phys-
icians of Canada (CFPC).
Fast forward 15 years and the situation
is similar in the United Kingdom, said
Dr. Katie Coleman, clinical lead for pri-
mary care across north London. She
described a “significant shortage” of gen­
eral practitioners (GPs) in the National
Health Service, with numbers declining
and rural areas going underserved.
Canada has bolstered students’ career
choice of family medicine, partly by rec-
ognizing family medicine as a specialty in
its own right in 2007. Coleman and many
others think such recognition would help

2. in the UK as well. The CFPC had the
authority to declare family medicine a
specialty, but such recognition in the UK
must overcome a legislative hurdle. “The
Medical Act 1983 has to be changed,” said
Coleman. “We would have done this sev­
eral years ago if it wasn’t for that.”
Coleman started a petition to have
general practice so recognized, but she
said she will not get the 10 000 signatures
needed in a six-month period to trigger a
mandatory response from the govern-
ment. However, efforts by other advo-
cates, including the Royal College of Gen-
eral Practitioners, will continue.
Does calling family medicine a spe-
cialty really make a difference in recruit-
ment of family docs? “I would like to
believe that it does,” said Dr. Heather
Osborn, a specialist in head-and-neck
surgical oncology at Yale University, who
conducted a study of factors in residency
choice at Western University in London,
Ontario.
T h e s t u d y f o u n d “ t h r e e d i f f e r e n t
broad areas that predisposed students to
choose primary care,” said Osborn. Those
areas are work–life balance, duration of
program (two years instead of five), and
the physician–patient relationship (hav-

3. ing a long-term relationship with patients
and providing comprehensive care). But
students were drawn to other specialties
by factors that included “becoming an
e x p e r t , ” “ p o t e n t i a l l y e a r n i n g a h i g h
income,” and “perceived status among
colleagues.”
Osborn thinks seeing family physicians
as high-status experts will require a cul-
tural shift. “That idea of the family practi­
tioner as a gatekeeper who passes on
problems to specialists is not the reality
any more. Family physicians have a
NEWS
Recognition of family physicians as experts
rather than gatekeepers requires “cultural
shift”
n Cite as: CMAJ 2018 April 30;190:E550-1. doi:
10.1503/cmaj.109-5591
Posted on cmajnews.com on Apr. 11, 2018.
Many family doctors in the UK want their profession recognized
as a speciality, as it has been in
Canada since 2007.
AJ
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at
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4. iS
to
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CMAJ | APRIL 30, 2018 | VOLUME 190 | ISSUE 17 E551
spectrum of care that they have a high
level of expertise in.”
Lemire says that shift has been “a jour­
ney,” with milestones in 1967 (when the
College of General Practitioners of Can-
ada became the College of Family Phys-
icians of Canada), in 1974 (when the first
family medicine residencies were insti-
tuted), and in the 1990s (when such dedi-
cated training became generally accepted
within the profession). In 2007, “we had
reached a point in our evolution that
there was recognition that family medi-
cine had its own body of knowledge, atti-
t u d e s a n d s k i l l s , w i t h c e r t i f i c a t i o n
through a summative evaluation. It was
appropriate for us to declare family medi-
cine as a specialty.”
She credits the change with helping to

5. turn around the dire situation in primary
care. “We did subsequently witness a steady
increase in the number of graduating medi-
cal students who chose family medicine,”
she said. She believes a recent dip is due to
specific issues in certain provinces.
In the UK, however, general practice
continues to get a bad rap. A recent report
from the Royal College of General Practi-
tioners stated that 76% of medical stu-
dents hear disparaging remarks about
family medicine from clinicians, educators
and academics. The survey of 3680 British
medical students also found that 91% of
them believe their peers hold negative
attitudes about general practice.
Medical students often ask each other,
“What are you going to specialize in or are
you just going to be a GP?” said Coleman.
“It’s a problem getting students to even
consider it as a highly respected specialty.
It’s only when they get a taste of general
practice that they see it’s a great practice
to go into.”
Carolyn Brown, Ottawa, Ont.
Reproduced with permission of copyright owner. Further
reproduction
prohibited without permission.

6. Government Intervention
“Many clients will look to Social Security to supply an
important portion of their retirement incomes. Even if a client
does not anticipate needing Social Security benefits to pay for
his or her living expenses, the benefits can still provide a
sizeable income stream that can affect other financial decisions.
Understanding Social Security benefits can help clients and
financial professionals make more informed retirement planning
decisions” (Tannahill, 2013, p. 27).
1
Introduction
Social Security
Government Intervention Reasons
Market Base
Solution
s
Selected Government Intervention
Cost Trends
Conclusion
References

7. 2
Social Security Retirement Benefits
The original Social Security Act, was signed into law on August
14, 1935, grew out of the work of the Committee on Economic
Security, a cabinet-level group appointed by President Franklin
D. Roosevelt just one year earlier. (Martin & Weaver, 2005)
The Act created several programs that, even today, form the
basis for the government's role in providing income security,
specifically, the old-age insurance, unemployment insurance,
and Aid to Families with Dependent Children (AFDC)
programs. The old-age program is, of course, the precursor to
today's Old-Age, Survivors, and Disability Insurance, or Social
Security, program. The original Act also provided federal
support for means-tested old-age assistance programs run by the
states, which were eventually transformed into the current
Supplemental Security Income (SSI) program” (Martin &

8. Weaver, 2005). The Great Depression was a catalyst for the
creation of the Social Security program, the idea of social
insurance predated the committee's work and the Depression. As
early as the 1880s, Germany had built a social insurance
program (one requiring contributions from workers) that
provided for sickness, maternity, and old-age benefits (Martin
& Weaver, 2005). These benefits were given to individuals who
were 65 years are older who were not working. “
3
Replacement rates for scaled workers retiring at age 65, by type
of earner, 1940–2003
Chart 5.
Replacement rates for scaled workers retiring at age 65, by type
of earner, 1940–2003. SOURCE: Tabulations were done by the
Office of the Chief Actuary, Social Security Administration
The 1939 amendments defined the test of retirement (commonly
referred to as the retirement earnings test) as earnings of less
than $15 a month; earnings in excess of this amount precluded
payment of benefits. Changes to the earnings test are an

9. important policy theme in Social Security's history. In fact, in
2000, the retirement earnings test was completely repealed for
beneficiaries older than the currently defined full retirement
age” (Martin & Weaver, 2005). In the 1940’s “President
Roosevelt vetoed the legislation in 1943 that prevented a
scheduled tax increase from taking effect, but the veto was
overridden in Congress. The Roosevelt administration argued
that it was inappropriate to leave future administrations and
Congresses with large benefit liabilities (once the program
matured) and a limited reserve fund. However, a coalition of
lawmakers who were opposed to reserve funding and tax
increases prevailed. The paradox of the 1940s is that the robust
economy led to a substantial buildup of reserves (even at the 2
percent combined payroll tax rate) but that proponents of the
reserve approach to financing lost the political argument over
tax increases. As a result, debates about reserve funding died
down until the amendments of 1977 and 1983, and the Social
Security program operated for many years as if it were
approximately following a pay-as-you-go, or pay-go, approach
to funding benefits” (Martin & Weaver, 2005).
4
Government Intervention

10. “The amendments of 1983 established the general policy
structure of the current Social Security program and, in
particular, its current financing structure. The direct and
dramatic result of the financing structure in the 1983 law was a
massive buildup in the size of the trust fund reserves” (DeWitt,
2010, para. 1).
“Historically, the Social Security trust funds have never been
either fully funded or on a strict pay-as-you-go (PAYGO) basis.
Rather, the trust funds have always contained what former SSA
Chief Actuary, Robert J. Myers, characterized as a "partial
reserve." We can conceptualize these two extremes (a fully
funded system and a PAYGO system) as the end poles of a
continuum. Over the decades, major legislation has tended to
move the placement of the reserve in one direction or the other.
Both the 1977 and the 1983 amendments shifted program policy
noticeably away from the PAYGO end and significantly toward
the fully funded end of this continuum (Myers 1993, 385–392)”
(DeWitt, 2010, para. 2).
“The design of the 1983 financing scheme produced a large
buildup of the reserve in the near term so that this source of
investment income might help defray future costs when the

11. "baby boom" generation began to move into beneficiary status.
The effect of this approach to program funding can clearly be
seen in Chart 3” (DeWitt, 2010, para. 3).
5
Trust fund reserves: Actual and projected, selected years 1983–
2037
Trust fund reserves: Actual and projected, selected years 1983–
2037. SOURCE: Annual Trustees Report, 2009, Table V1.A4
and Table V1.F7. (DeWitt, 2010).
6
Market Based