Whether family doctors want to admit it or not, the profession is facing serious long-festering problems. As one Facebook respondent correctly pointed out, there's no sky-is-falling imminent doom for family medicine. Family docs are still the cornerstone of primary care and are largely indispensable to the health care system as a whole. However, I think we'd be naive to think that the practice of Family Medicine As We Know It isn't endangered. Why?
Medicine is unique among the professions in its balance of job security, income security, and above all autonomy. The freedom doctors traditionally (but not always) enjoyed to tailor their work habits and practice profiles tended to suit everybody fine - except politicians and pundits - because doctors were dawn-to-dusk workaholics. That is increasingly no longer the case, and I say that without passing judgment. Though medical school tuition skyrocketed from the late-90s onward, pembinaan a doctor still costs the government hundreds of thousands of dollars, nearly an order of magnitude more than the cost of pembinaan a nurse. So despite ever-growing student debts and the abysmal conditions of residency, the government (and therefore the public) has a not-illegitimate "claim" on where and how doctors practice, especially if they aren't working the same long hours of yesteryear.
The proffered solution lay in that Holy Grail for health-care pundits, primary care reform (PCR). Working in teams, capitation, EMRs, performance incentives...everyone could have their cake and eat it too. The College of Family Physicians put out its vision for the Patient's Medical Home, a model of practice enshrining the exalted Four Principles of Family Medicine.
Though not a Muppet Labs-level disaster, bloated bureaucratic oversight? Team-based care is essential for CHCs and their marginalized clientele, and probably for frail seniors as well. But for most of the population PCR was always a solution in search of a problem. And shock of shocks, people won't always get along with their coworkers.
What about comprehensiveness? Wellness, rather than illness care? Caring for the entire patient over the long run, instead of just their BP or lipids? Don't you need a non-FFS remuneration to do that effectively?
Hmm...
First, good, conscientious doctors have always practiced good, conscientious medicine, regardless of how they were paid. And cared for their patients to the best of their ability, within the limits of what the respective personalities of doctor and patient allowed (we can't all love all of our patients, just as the reverse is true).
What exactly is "wellness care"? Annual physicals, that are pretty much a ever-expanding waistlines of Canadians? Do we know anything reliable about nutrition nowadays? Immunizations and breastfeeding advice? Yes we do our part, but those are properly the responsibility of public health authorities (for which they are funded and held to account for).
What about that straightforward stuff, the number chasing - lipids, heartburn, blood pressure - that pharmacists and NPs feel confident they can handle. Let them do it! Why make preposterously-educated doctors do such mundane work?
Doctors need to do what only doctors can do, and what only doctors are trained to do, i.e. the accurate diagnosis and treatment of medical conditions. Nowhere in the Oath of Hippocrates is it written that we must play along with ill-conceived designs of bureaucrats and health researchers.
So what does an evolved family doctor look like?
A competent, confident clinician. Not a nanny or cherished friend to everyone that walks in the door. Not a salesperson, pushing pills and diets in the name of risk reduction. Not a lemming, tailoring work habits to suit benchmarks and targets set and enforced by people with no credentials as health care professionals.
An independent practitioner, within limits. The state has a legitimate claim on a doctors' service, and that must be respected. The most straightforward approach is some sort of mandatory return-of-service, which can take many, many forms. Doctors should not see that as punishment but rather opportunity, a chance to gain an entirely different set of (Canadian) work experiences before settling down.
The other limit that doctors need to accept is that refusing to treat certain problems - usually chronic pain, but I've seen highly complex medical patients turned away too - because of "not feeling comfortable" is a bridge too far. Going into depth on this is an argument for another day. Suffice it to say for now that the freedom to decline bureaucratic control and the freedom to decline a priori the person walking into your exam room are far apart on the doctors' autonomy spectrum.
As I noted in a prior post, the move to competency-based pembinaan creates a wealth of opportunity to make family medicine a true specialty. Mix-and-match elective experiences and/or a third year of residency to tailor your career to your professional goals. Does a doctor need a full year to focus on women's health, to the exclusion of other interests? What about six months of palliative care and six months of psychotherapy, to become a doctor specializing in a whole-family approach to end-of-life care and grief counseling? Or extra pembinaan in dermatology, general surgery, and plastics/wound care to become the local lumps-and-bumps doc?
Yes, doing away with the comprehensive PCR vision could mean less predictable income, and even less money overall. But one of the primary predictors of outcomes in mental health is a person's sense of control. There's more than enough evidence that governments are looking to seize control of medicine and turn it into a form of public service, albeit with no semblance of the benefits, security, coverage of expenses, and pensions that normally go along with proper civil service employment.
There's an argument to be made for, again using the Aikido philosophy, accepting this power grab by the politicians and bureaucrats but pushing it further. Family doctors can seek real solidarity. Instead of relying upon hapless, fractured, and ineffectual medical associations, doctors can demand salaried employment and form a proper union.
Personally, I think doctors are by and large too innately driven and independent to go down this road - even the most humble family doctor had to be a bright, driven overachiever to get in the door - but it's a hard decision that needs to be made, and needs to be made soon.
Family doctors must not accept second-class-citizen status in health care. Direct opposition isn't likely to work, and even if it does will leave many physicians exhausted and demoralized from the battle, as it already has. The best bet is to seize control of what you can control, namely the definition of doctor.
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Friday, June 10, 2016
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