Tuesday, May 17, 2016

No Bureaucrat Left Behind, Part III

Some sensible ideas around primary care for the next Minister of Health.

While I would still argue that hospital overcrowding and the lack of long-term care capacity are far more urgent problems, let's assume that reforming primary care is a legitimate priority.

To recap, Patients First looks to fix four key problems with Ontario's primary care system:

  • poor access to after-hours care, despite all the group practice models and incentives and sticks in place
  • closed primary care practices
  • poor geographic distribution of doctors
  • a lack of succession planning in primary care, which magnifies the first three
I've previously noted that there have been secular changes in the makeup and practice patterns of family doctors. Many more primary care doctors are women, and men and women alike are working few hours. My hunch is that these shifts are irreversible. The romantic ideal of a doctor, caring for patients from dawn 'til dusk until he (back then it was always a he) drops dead at his desk, needs to go the way of the dodo. These trends need to be acknowledged as facts, since they've taken place regardless of pay increases and newer practice models. 

Accordingly, simply offering more incentives for doctors to relocate to rural locations isn't going to work. As both the Barer-Stoddart and Romanow reports argued, such incentives tend to cause wage inflation, as rival communities rob Peter to pay Paul to recruit family doctors. While doctors might be happy with that, it's bad public policy.

Consequences, schmonsequences, as long as I'm rich
Likewise, IMGs aren't a panacea either. Setting aside the roadblocks to licensing, Barer-Stoddart noted that adherence to return-for-service agreements is far from perfect. Moreover, once the IMGs complete their of the agreement, they will often relocate near larger communities of their country of origin. Since ethnic communities are more often found in large cities, this aggravates the urban/rural maldistribution of doctors in the long run.

So what steps might be more promising?

Many more Community Health Centres, with many more Nurse Practitioners. No, NPs don't replace doctors, and don't see as many patients in the run of a day. However, they're much quicker and less costly to train. They also come from a different place culturally that makes them well suited to primary care (I'll go into more depth on this in a future post). Moreover, a huge chunk of family medicine is mundane, straightforward, and/or chronic disease management. NPs can and should do much of this work. Two NPs doing 80% of the work of a doctor is both economical and a good answer for many communities. The only time debating "doctors vs. NPs" makes any sense is in the face of a glut of family doctors. 

The CHC model works well for a few reasons. It's locally established, and locally governed. It can make changes to its mission and practice patterns without resorting to a laborious renegotiation of its legal contract. And if a practitioner leaves or retires, the CHC retains an "institutional knowledge" of the patient beyond the old records. A CHC need not cost a lot of money to set up. Most importantly, the administrative infrastructure of the CHC serves the patients and the community, not just the bureaucracy. That's the most glaring problem of Patients First...even if everyone plays along, and the Price-Baker vision can be implemented, how much has been spent before a single patient is seen?

Newly licensed doctors have a mandatory two-year obligation in underserviced areas, acting as salaried medical consultants to a CHC. It's blunt, it's not nice, but it eliminates the clunky New Grad Program bureaucracy and all the headaches that entails. It ensures a predictable level of medical care across the province, 100% predictable costs, and does away with the auctions that take place between small towns. And you know what? Sometimes a young doc might actually like working in an underserviced area, and decide to stay.

Establish a fund for communities to finance stop-gap coverage for sudden practice closures. There are private (take that, socialists!) companies out there that specialize in providing urgent locums and ER coverage, with sizable networks of on-call practitioners at their fingertips. I won't name them (unless they want to cut me a cheque), but they aren't hard to find. If an isolated or ethnically-concentrated community loses its doctor suddenly, it makes more sense to simply hire (or tender) these firms to arrange staffing on an urgent basis, while a more viable long-term solution is figured out. Again, an imperfect solution, but a lot less onerous than the Price-Baker model.  

Finally, and perhaps most controversially...

Rethink what a family/general doctor is supposed to be. The College of Family Physicians has started navel-gazing around this issue, though I would argue without nearly enough urgency. New family doctors are rejecting the romantic comprehensive care ideal in droves. Put together with the changes in practice patterns, the Family Doctor as currently espoused might be in need of a physician-assisted death.

This doesn't mean we don't need general practitioners, far from it. However, a doctor's fundamental skills lie in diagnosis and treatment, not (drug-company driven) chronic disease monitoring or counseling. Diagnostic and therapeutic expertise is where a nurse or NP can't substitute for an MD, nor should they. Likewise, a social worker is usually a much better counselor than I am, an opinion I suspect I share with many FPs out there.  

The shift in medical education to competency-based training opens many doors if the Royal College and CFPC can come down from their high horses about keeping generalist and specialist certification oceans apart. Why not explore a two or three year "general physician" designation, with more mixing-and-matching of training opportunities, more paths to change career directions while still a resident, and more ways to shift scope of practice down the road? It's not a question of income, but rather professional satisfaction and prevention of burnout.

I never profess to have all the answers, but I know a bad plan when I see it. Patients First is guaranteed to cause disaster and waste on a grand scale, with no foreseeable boon to the citizens of Ontario (that don't work for the government).

It's just One Asshole's Opinion, but at least it's informed.


  1. Interesting ideas. don't agree with limiting choice of MDs who have put in the work and hours of the long grind to become MDs and have the heavy responsibility that comes with being an MD. Also NPs see less than a quarter the # of patients a GP sees and who are you to say GPs shouldn't manage chronic care and, aren't good at/don't like counselling?

    1. Thanks for the comment. Had a lively debate on Twitter last night around these ideas. At issue is the hard reality of doctors avoiding rural life and (increasingly) rejecting "classic" comprehensive family medicine. For many reasons, these trends are probably irreversible. Yes, you could dramatically increase the number of doctors, but admissions to med school have almost doubled in the past 15 years with no improvement in access, in particular in rural areas.

      Nobody likes the idea of a forced return-of-service, but the government underwrites medical school to the tune of hundreds of thousands per student, far more than other programs. NPs cost much less money and time to train. No they can't do it all, nor see as many people, but absent a way to get MDs to work where they haven't wanted to for decades, what's the alternative?

      With regards to what a GP should and shouldn't do, there's nothing to say they can't do it. But MDs are a scarce resource in underserviced areas (rural and inner-city). You need to maximize their time doing what only MDs can do.

      Someone brought up the idea of new docs performing telemed consults as a return for service. I also didn't realize that some residency programs have no rural components. That struck me as crazy, not only because of the "public service" aspects of rural medicine, but because the experience is varied and fantastic. Rural medicine should be a mandatory part of training. These are constructive ideas.

      Unfortunately, the sub-LHIN Price-Baker model will waste untold millions before a single patient is seen. It's putting far too much faith in the skills of bureaucrats.

      At the end of the day, I have no power or influence. If policymakers listened to people on the ground, we wouldn't need blogs like this.