Tuesday, June 7, 2016

Does Family Medicine Have a Future? Part I

Time to open a can of worms about the inconvenient truth of the 800-pound gorilla riding the elephant in the room.

Disclosure: I have some very good friends that are nurse practitioners (NPs), though to the best of my knowledge I don't owe any of them money.

It's hard not to be nervous if you're a Canadian family doctor these days. Sure, specialists are crying foul about not finding jobs or having their billings splattered all over the front page, but is that really so different from complaining about a lack of OR time or stagnant procedure fees (which has gone on forever)?

I'm not referring to the age-old lack of prestige associated with family medicine, or the just-as-age-old critiques of how family doctors should or should not be paid. No, I mean the wild and draconian steps provincial governments are taking to dictate the way Canadian family doctors practice, regardless of how they're paid. Nova Scotia has enacted a convoluted system of credentialing family doctors. God only knows what will happen in Alberta, now that the cratering price of oil has tanked the provincial economy, and the province's economic engine is now cinders and ash. And after three prior posts to the topic, I don't think much more needs to be made of Ontario's Patients First, at least until the details of implementation come out. But hey, there's going to be hotline for those assisted death referrals!

We also seem to be in somewhat uncharted waters in the history of family medicine. Long considered to be an inferior substitute for a fully trained physician, NPs are coming into their own in the eyes of policymakers. Add in the long-term secular trends in the way family medicine is being practiced and the aforementioned government micro(mis)management, and you wouldn't be off base in wondering whether the profession has much of a future.

Scientists use the term convergent evolution to describe the phenomenon in which different species develop similar body structures via dramatically different paths. Birds are thought to descend from sauropods - cold-blooded avian reptiles, while bats share the common mammalian ancestry of rodents. Both have wings with wide spans relative to vertebral length, and both use those wings for flight. The same can be said of the fins on sharks (a species of fish) and whales (an oceanic mammal).

The same thing is happening in family practice.

Doctors (mostly) start their careers as scientists, and are trained to become caregivers.

Nurse Practitioners start out as caregivers, and are trained in the knowledge and skills needed to diagnose and treat.

NPs aren't doctors, and the ones I've come to know don't profess to be. They can't see as many patients in a day, are seen by many as more costly in the long run (although there are too many balls in the air to answer that definitively). Nevertheless, NPs have built a sizable education infrastructure, are amassing ever more experience collectively, and have developed a pretty broad scope of practice. The discipline has matured and evolved into something beyond what doctors probably foresaw. Still, that's not sufficient to explain why policymakers see NPs as viable replacements for family doctors.

The other problem is that medicine, in particular family medicine, has been DUMBED DOWN. Flowsheets, guidelines, diagnostic checklists, treatment targets, structured interviews, self-assessment sheets...the unintended consequence of the explosion in research in recent decades (industry-driven or not) has been a standardization of large chunks of medicine, to the point that a child could practice it. I'm not just talking about the stuff we raise our eyebrows at, like tear-off sheets for patients to self-diagnose adult ADHD. Take for example the simplified Alberta guidelines for lipid management. It's terrific that FP-researchers reviewed reams of evidence and concluded that a single blood test and risk calculation is all that's needed to guide the treatment decision, with no further follow-up required. As a consequence, however, anybody can manage this condition. The same holds true for high blood pressure, asthma, pregnancy, diabetes, osteoporosis, well-baby visits, and so on.

Now factor in the part of medicine that's always been pretty straightforward, and the assertion that patients have been conditioned to seek medical care for anything and everything (since every symptom now has a clinical-ish name attached to it).

As doctors have been rejecting comprehensive care and steadily scaling back their hours for years, is it any wonder that people in power don't think all that highly of family doctors anymore?

The reflexive response of treating the encroachment of NPs on traditional family medicine "turf" as a threat is understandable. So is outrage over the notion that doctors can be supplanted by other health professionals working to the limits of their scope. Nevertheless, knee-jerk opposition hasn't proven effective to date, and in the absence of (hazardous) job action, is unlikely to make a government change course.

So that's it? Family doctors just roll over and accept a slow and inexorable decline?

Nope...family doctors should evolve. Next time.

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