What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Tuesday, October 23, 2007

A Cure For What Ails Family Practice

I’m not sure if Dr. Tom Feasby (Dean of the faculty of Medicine at the University of Calgary) is truly unaware of the reasons traditional family practitioners are going the way of the Dodo bird or whether he was simply providing the public with a somewhat palatable, politically correct, placebo, in his Calgary Herald dissertation “A cure for what ails family practice”. Although he did bring forward some crucial issues like family medicine remuneration and disparities in specialist/family doctor incomes, he waters down the problem by mentioning a recent increase in fees, and the government overhead subsidy program, both designed to maintain the status quo and won’t come close to addressing these two critical issues. He then states “This is an issue the Alberta Medical Association is working on and requires an effective solution”. Here is a news flash! The AMA has been “working on” this since the early 1970’s when I was chair of the Incomes Committee and has not, and likely will not, ever address the issue effectively.
It is unlikely that a solution will arise for “what ails family practice” when our Dean of Medicine fails to mention one of the main reasons for the decline in traditional family practitioners, ie., burn out, or the prospect of burnout, of traditional family physicians in the present Canadian system. When we as primary health care providers feel a patient should be seen by a specialist in two weeks and they are seen in two months, when our patients are in pain and require intervention and wait months for relief, while we feed them drugs that impair their mental capabilities or put them at risk for heart attacks and/or falls, we go home each day with the knowledge and the feeling we have failed our patients. As a result, retirements are accelerated and greener pastures are sought. And I’m sorry, Dr Feasby, but exposing bright your minds to this reality, coupled with the income disparity, will not encourage new graduates to become family practioners.
Of more concern to me, not that I blame them in the least, is the trend for young graduates who go into family medicine to “take the path of least resistance”. Dr. Feasby brings this forward as a positive and states “Calgarians also need to be aware that although traditional family practices are not as common today, many family medicine graduates are choosing to practice in high demand areas such as emergency medicine, palliative care, low risk maternity, and care of the elderly”. Excuse me? Why are these high demand areas? Could it be that FIRST there has been a decline in TRADITIONAL family practices that at one time was comprised of all of the aforementioned areas.
This ongoing disintegration of family medicine has continued and now excludes hospital care, nursing home care, and for that matter, people who are genuinely and acutely ill. In some offices, the front desk triages sick people to the emergency departments or walk in clinics, and the physician only sees the regular booked appointments. The system has fostered, almost mandated, this scenario. After doing closed fractures for 35 years, the Rockyview Hospital Cast clinic advised me that any booked fractures for casts in the cast clinic would have to be done through the Emergency department. My obvious response was then to advise my receptionist that any phone calls from patients that may have a fracture should be sent directly to the emergency department. Why should I see the patient, send them for an X-ray, look at the X-ray, know they need a cast, but then send them to an emergency department to incur more cost and wait for hours to be told the same thing by the emergency physician and then booked next day at the cast clinic? But I digress.
The truth is that physicians have responded to their inability to access resources by:
1) Avoiding traditional family practice where they have the responsibility for both short term AND long term outcomes. Following patients who have significant medical needs that are not being met by the system in a timely way, you, as the patient’s advocate and friend, suffer with the patient. I found it amusing that Dr. Feasby felt that the qualities of compassion and caring in a medical student would lend itself to being a good traditional family physician. It also lends itself to early burnout in our present day system.
2) Some physicians have taken on the role of “hospitalist”. Although this area of care is stressful, there is less personal involvement in the care of the patient, with the primary area of responsibility addressing the acute care needs. Specialists and resources are usually readily available as early discharge is seen as being cost effective. The time of responsibility is clearly delineated into shifts, and there is very little if any administration required.
3) Working as a locum (covering for family doctors when they are away) requires responsibility for the time you are covering, and an easy approach for difficult access situations is “see your doctor when he gets back” or more urgent situations can be foisted onto the emergency departments.
4) Contrary to the implication by Dr. Feasby that part of the shortage of traditional family doctors is that they are turning to palliative care duties, there is, in fact, a severe shortage of family doctors willing to be involved in palliative care and the care of the elderly. This again is because of the time issues involved (we get paid per visit with little regard for time spent), complexity issues (requires more time and involvement), and the difficulty accessing resources (these are groups that need timely intervention and resources). Meanwhile, in spite of these factors, Alberta continues to have a small differential in fees for elderly patients and complex problems compared to other Canadian provinces.
5) At present, walk-in clinic work seems to be the most attractive alternative for physicians coming out of family practice training. However, this service is, for the most part, episodic care, and addresses cases on a presentation bases with whichever doctor is available, rather than a health and disease management basis. As such, patients see different doctors at different times, and the turnover per hour is high affording a better income. As a response to this inequity, many traditional family doctors have limited patients to “one complaint”, thereby raising the obvious possibility of missing several complaints that point to one diagnosis.
In summary, I was very disappointed in Dr. Feasby’s “Cure for what ails family practice” article in the Calgary Herald. He seems to have not taken an accurate history or done a thorough examination, and he certainly has prescribed treatments that have been tried and failed, or, at the very least, have “not been proven”. Until we pay family physicians for the time, complexity, and responsibility they take; AND until we provide the resources for them to perform their duties in a manner that enables them to feel, at the end of the day, that they have provided a valuable service to the patient, we will continue to see traditional family medicine disappear over the horizon like Tom Mix in an old western movie. As the Supreme Court has stated “Access to a waiting list is not access to Healthcare”. No one in the medical profession understands and feels this more than the caring, compassionate traditional family physician.


Anonymous Sue said...

What do you think about the new multi-disciplinary clinics being introduced?

26/10/07 9:16 PM  
Blogger Al said...

There are several aspects that are problematic for many family doctors.
1) A team is only as good as its weakest member, and the family doc isn't likely to get to choose his/her team.
2) As I understand it, although all members are considered to be equal "partners" in the team, legally, if the doctor is involved in the decision making there will be considerable oness on him/her from a medical legal perspective if something goes wrong.
3) The cost effective aspect is to be derived from the principle of each person in the team performing to their trained capability. This means that minor things, and things that fall into a specific area (nutrition councelling nurses/nututionists, minor pains and muscle problems eg physio, sore throats and respiratory infections eg physician extender, blood pressure and blood sugar control eg nurse practitioner, etc. will be seen by someone other than the physician and some type of triaging will be required. The end result will be that the physician will be seeing very ill people. At present that is not the case, particularly in some practices. If I am going to spend my time seeing very ill people with multi-system failure, etc, instead of a "mix" of ill and not so ill people, I am going to want to be paid an awfull lot more money or given alot of other "perks".
4) Since I will be seeing sicker patients and more complex illnesses, my need to have quick access for MOST of my patients to investigative tools and specialists is imperative or suffer more stress, feelings of failure, etc and face early burnout. And again, will I be compensated for that scenario? Mind you, your care of patients within such clinics would be shared by many others and less personal so maybe the physician could survive by practicing in a more detached, consultative manner. Is that what we want in our family physician?

27/10/07 1:42 PM  

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